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Background: A suspicious occlusal carious lesion (SOCL) can be defined as a lesion with no cavitation and no radiographic radiolucency but for which caries is suspected. The authors evaluated whether using a device changed the percentage of SOCLs that were opened surgically and, among those SOCLs that were opened, the proportion that had penetrated into dentin., Methods: Eighty-two dentists participated. In phase 1 of the study, dentists identified approximately 20 SOCLs, obtained patient consent, and recorded information about the lesion, treatment or treatments, and depth, if opened. Dentists were then randomly assigned into 1 of 3 groups: no device, DIAGNOdent (KaVo), and Spectra (Air Techniques). In phase 2, dentists enrolled approximately 20 additional patients and recorded the same phase 1 information while using the assigned device to help make their treatment decisions. A mixed-model logistic regression was used to determine any differences after randomization in the proportion of lesions opened and, if opened, the proportion of lesions that penetrated into dentin., Results: A total of 1,500 SOCLs were enrolled in each phase. No statistically significant difference was found in the change in proportion of lesions receiving invasive treatment from phase 1 to phase 2 across the 3 groups (P = .33) or in the change in proportion of percentage of opened lesions that extended into dentin (P = .31)., Conclusion: Caries-detecting devices in the study did not change substantially dentists' decisions to intervene or the accuracy of the intervention decision in predicting lesion penetration into dentin., Practical Implications: The caries-detecting devices tested may not improve dentists' clinical decision making for SOCLs., (Copyright © 2018 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Objective: Case presentations (vignettes) were completed by dentists in the National Dental Practice-Based Research Network study "Decision Aids for the Management of Suspicious Occlusal Caries Lesions (SOCLs)". The objective was to determine dentists' decision strategies for SOCLs., Methods: 107 dentists viewed a series of 16 vignettes that represented all combinations of 4 clinical cues: color, luster, lesion roughness, and patient-level caries risk. Each vignette included a patient description and a photograph of a tooth presenting the 4 cues. Dentists were asked to decide the likelihood that a suspected lesion extended into dentin. A lens model analysis was used to examine how dentists use these cues in making their decisions., Results: 86% of dentists had a consistent pattern of cue use that defined their decision strategy. On average, 70% of the variance in their decisions was accounted for by their use of the 4 cues. However, there was considerable variability in the individual cues used by each dentist. The percentages of dentists who used the different cues consistently were: luster (58%), color (48%), roughness (36%), and risk (35%). 14% of dentists reliably used only color, 7% used only luster, 4% used only roughness, and 1% used only risk when making SOCL decisions., Conclusions: The online vignette system suggests that clinical SOCL decision strategies are highly individualized and dentists do not use all cues available to them to make these decisions., Clinical Significance: Prior to this study, there has been little evidence about how dentists use these cues (either individually or in combination) when judging the extent of caries progression. Such knowledge would be valuable when designing interventions to help dentists maximize the likelihood of appropriate treatment decisions., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: A lesion on an occlusal tooth surface with no cavitation and no radiographic radiolucency but in which caries is suspected owing to surface roughness, opacities, or staining can be defined as a suspicious occlusal carious lesion (SOCL). The authors' objective was to quantify the characteristics of SOCLs and their relationship to lesion depth and activity after these lesions were opened surgically., Methods: Ninety-three dentists participated in the study. When a consenting patient had an SOCL, information was recorded about the tooth, lesion, treatment provided, and, if the SOCL was opened surgically, its lesion depth. The Rao-Scott cluster-adjusted χ 2 test was used to evaluate associations between lesion depth and color, roughness, patient risk, and luster., Results: The authors analyzed 1,593 SOCLs. Lesion color varied from yellow/light brown (40%) to dark brown/black (47%), with 13% other colors. Most (69%) of SOCLs had a rough surface when examined with an explorer. Over one-third of the SOCLs (39%) were treated surgically. Of the 585 surgically treated SOCLs, 61% had dentinal caries. There were statistically significant associations between lesion depth and color (P = .03), luster (P = .04), and roughness (P = .01). The authors classified 52% of the patients as being at elevated caries risk. The authors found no significant associations between lesion depth and patient risk (P = .07)., Conclusions: Although statistically significant, the clinical characteristics studied do not provide accurate guidance for making definitive treatment decisions and result in high rates of false positives., Practical Implications: Given that 39% of the opened lesions did not have dentinal caries or were inactive, evidence-based preventive management is an appropriate alternative to surgical intervention., (Copyright © 2017 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Background: The objectives were to: (1) quantify patient satisfaction with treatment for early dental caries overall, and according to whether or not (2a) the patient received invasive treatment; (2b) was high-risk for dental caries, and had dental insurance; and (3) encourage practitioners to begin using non-invasive approaches to early caries management., Methods: Ten practitioners recorded patient, lesion, and treatment information about non-cavitated early caries lesions. Information on 276 consecutive patients with complete data was included, who received either non-invasive (no dental restoration) or invasive (dental restoration) treatment. Patients completed a patient satisfaction questionnaire and were classified as dissatisfied if they did not "agree" or "strongly agree" with any of 14 satisfaction items., Results: Patients had a mean (± SD) age of 41.8 (±15.8) years, 64% were female and 88% were white. Twenty-five percent (n = 68) were dissatisfied in at least one of the 14 satisfaction items. Satisfaction levels did not significantly vary by patient's gender, race, caries risk category, or affected tooth surface location. Overall, 11% (28 of 276) received invasive treatment; satisfaction did not differ between patients who had invasive or non-invasive treatment. Seven patients received invasive treatment at their request even though that was not what their practitioner recommended; 5 out of 6 were satisfied with their treatment nonetheless., Conclusions: About one-fourth of patients treated for non-cavitated early caries were dissatisfied with at least some aspect of their dental care experience. Satisfaction of patients who received invasive treatment did not differ from those who received non-invasive treatment.

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., Methods: 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., Results: 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., Conclusions: 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., Practical Implications: 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.

Objectives: To better understand the effectiveness of xylitol in caries prevention in adults and to attempt improved clinical trial efficiency., Methods: 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., Results: 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., Conclusions: 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., (© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

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.

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., Results/conclusions: 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.)., Clinical Relevance: Our findings may help identify individuals at higher root caries risk.

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.

Objectives: This report describes the training of dental examiners participating in two dental caries clinical trials and reports the inter- and intra-examiner reliability scores from the initial standardization sessions., Methods: Study examiners were trained to use a modified International Caries Detection and Assessment System II system to detect the visual signs of non-cavitated and cavitated dental caries in adult subjects. Dental caries was classified as no caries (S), non-cavitated caries (D1), enamel caries (D2), and dentine caries (D3). Three standardization sessions involving 60 subjects and 3,604 tooth surface calls were used to calculate several measures of examiner reliability., Results: The prevalence of dental caries observed in the standardization sessions ranged from 1.4 percent to 13.5 percent of the coronal tooth surfaces examined. Overall agreement between pairs of examiners ranged from 0.88 to 0.99. An intra-class coefficient threshold of 0.60 was surpassed for all but one examiner. Inter-examiner unweighted kappa values were low (0.23-0.35), but weighted kappas and the ratio of observed to maximum kappas were more encouraging (0.42-0.83). The highest kappa values occurred for the S/D1 versus D2/D3 two-level classification of dental caries, for which seven of the eight examiners achieved observed to maximum kappa values over 0.90. Intra-examiner reliability was notably higher than inter-examiner reliability for all measures and dental caries classifications employed., Conclusion: The methods and results for the initial examiner training and standardization sessions for two large clinical trials are reported. Recommendations for others planning examiner training and standardization sessions are offered., (© 2011 American Association of Public Health Dentistry.)

Background: The authors conducted a study to identify factors associated with the materials that dentists in The Dental Practice-Based Research Network (DPBRN) use when placing the first restoration on permanent posterior tooth surfaces., Methods: A total of 182 DPBRN practitioner-investigators provided data regarding 5,599 posterior teeth with caries. Practitioner-investigators completed an enrollment questionnaire that included the dentist's age, sex, practice workload, practice type and number of years since graduation. When patients who had provided informed consent to participate in the investigation sought treatment for a previously unrestored carious surface, the practitioner-investigator recorded patient and tooth characteristics., Results: Practitioner-investigators used amalgam more often than they used direct resin-based composite (RBC) for posterior carious lesions. Practitioner and practice characteristics (years since graduation and type of practice); patient characteristics (sex, race, age and dental insurance status); and lesion characteristics (tooth location and surface, preoperative and postoperative lesion depth) were associated with the type of restorative material used., Conclusions: Several practitioner and practice, patient and lesion characteristics were associated significantly with use of amalgam and RBC: geographical region, years since dentist's graduation, patient's dental insurance status, tooth location and surface, and preoperative and postoperative lesion depth., Clinical Implications: Despite advances in esthetic dentistry, U.S. dentists still are placing amalgam on posterior teeth with carious lesions. Amalgam was used more often than RBC in older patients, who may have had deeper carious lesions.

As the number of dental-related randomized clinical trials (RCTs) increases, there is a need for literature to help investigators inexperienced in conducting RCTs design and implement studies. This commentary describes four "lessons learned" or considerations important in the planning and initial implementation of RCTs in dentistry that, to our knowledge, have not been discussed in the general dental literature describing trial techniques. These considerations are a) preparing or securing a thorough systematic review; b) developing a comprehensive set of study documents; c) designing and testing multiple recruitment strategies; and d) employing a run-in period prior to enrollment. Attention to these considerations in the planning phases of a dental RCT can help ensure that the trial is clinically relevant while also maximizing the likelihood that its implementation will be successful.

Purpose: The purpose of this study was to investigate the relationship between: (1) children's caries score (dmft, DMFT) at the time of sealant placement; and (2) "success" (measured as being caries-free) of that tooth at follow-up visits., Methods: An existing database of over 38,000 sealants (10,038 children) placed between 1997 and 2002 by the Jefferson County Health Department's Community Based Sealant Program, Birmingham, Ala, was used in the analysis. Only children returning for followup visits after the initial placement of the sealants were included in this study, resulting in 6,452 sealants (2,097 children). Logistic regression analysis was performed to determine the differences in sealant success between children with a dmft score of 0 vs a dmft score of >0 at baseline, and a DMFT score of 0 vs a DMFT score of >0 at baseline., Results: In the permanent and primary dentitions, those who had no caries at the time of sealant placement (dmft/DMFT=0) had a significantly higher success of sealants during years 1 to 5 compared to those with a caries score of greater than 0 (dmft/DMFT>0; P<.023, P<.002, respectively)., Conclusion: Children with previous caries experience may be at a higher risk for sealant "failure" (measured as caries on a tooth surface previously sealed) after 1 year and, therefore, may require more diligent sealant maintenance.

Purpose: The purposes of this study were to: (1) evaluate the retention rates of occlusal sealants in children in an urban school-based sealant program run by a County Health Department in Alabama; and (2) assess the clinical benefits of this sealant program by comparing caries experience of a group of participants and nonparticipants., Methods: The records of 2,097 children (mean age=8.1 +/- 1.6 years) who received sealants and had at least 1 follow-up examination were analyzed to determine the outcome of sealed and nonsealed surfaces of permanent first molars (PFM). Additionally, 103 fifth-grade students who did and did not participate in the sealant program (P=participants; NP=nonparticipants) were examined by a masked examiner who recorded their PFM condition., Results: Sealants placed by the County Health Department had a retention rate of 71% over an average of 1.6 +/- 0.7 years (range=0.5-4.4 years). The patient's age at the initial visit appeared to be the only factor that influenced retention. On average, participants had at least 1 PFM that remained caries-free, compared to nonparticipants (permanent decayed, missing, and filled teeth [DMFT] in NP=1.5 +/- 1.4, P=0.5 +/- 0.8; P<.016)., Conclusions: Retention rates for occlusal sealants in this public health program were similar to those reported in previous clinical studies. Furthermore, children who had sealants had significant protection from occlusal decay up to grade 5.

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. Methods. 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. Results. 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 clinicians deciding at some point after follow-up to seal the lesion or treat it invasively. Conclusions. 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. Practical Implications. 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. [ABSTRACT FROM AUTHOR]

Background. 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"). Methods. 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. Results. 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). Conclusion. Dentists reported a medium-range concordance between practice and published evidence. Practical implications. Efforts to bring research findings into routine practice are needed. [ABSTRACT FROM AUTHOR]