Future Perspectives in Pediatric Dentistry: Where are We Now and where are We Heading?

Oral diseases in children are still a major public health problem that can negatively impact parents and their children's quality of life. Even though oral diseases are largely preventable, initial signs of them can be detected in the 1st year of life, and its severity might increase with time if no preventive measures are taken. Based on this, we aim to discuss "where is pediatric dentistry now?" and "where is pediatric dentistry heading?" Early life oral health conditions are a good predictor of oral health status in adolescence, adulthood, and elderly people. A healthy childhood provides the foundation and opportunities for life; therefore, pediatric dentists have the unique opportunity to identify the presence of unhealthy habits in the 1st year of life and educate the parents and family members to change them for life. If all educational and preventive strategies fail or are not put into practice, the child might present oral health problems, such as dental caries, erosive tooth wear (ETW), hypomineralization, and malocclusion, that could have a great impact on other stages of life. At the moment, in pediatric dentistry, there are many alternatives to prevent and treat these oral health problems. However, if prevention fails, minimally invasive approaches, and new dental materials and technologies have been developed recently and will be important tools available in the near future in order to enhance children's oral health. How to cite this article: Rodrigues JA, Olegario I, Assunção CM, et al. Future Perspectives in Pediatric Dentistry: Where are We Now and where are We Heading? Int J Clin Pediatr Dent 2022;15(6):793-797.

Erosive Tooth Wear and Erosive Esophagitis in Children: An Observational Study in Porto Alegre, Brazil.

The aim of this study was to establish and compare the prevalence and severity of erosive tooth wear (ETW) in children with and without erosive esophagitis. Children aged 5-12 years, scheduled for upper digestive endoscopy at the Pediatric Gastroenterology Service of the Children's Hospital Santo Antonio, Porto Alegre, Brazil, were eligible to participate in this study. Patients who presented erosive esophagitis at endoscopy were defined as gastroesophageal reflux disease (GERD) carriers, and the severity was described according to the Los Angeles classification. The oral cavity examination was performed by a trained and calibrated dentist and ETW was classified using the Basic Erosive Wear Examination (BEWE) index. Parents/guardians answered a questionnaire about the patients' diets and frequency of consumption of acidic foods and beverages. A total of 110 children were included in the study. Erosive esophagitis was observed in 24 patients (21.8%) and all of them (100%) presented ETW, showing a statistically significant association between these 2 conditions (p < 0.05). Among children who did not present with erosive esophagitis (n = 86), 54 (64.3%) had an ETW risk level of none according to their BEWE scores (0-2). The results of this study showed a statistically significant association between erosive esophagitis and ETW, thus it can be concluded that it is important to recognize groups at risk of ETW and act together with medical professionals to ensure adequate oral health for these patients.

Do undergraduate dental students perform well detecting and staging caries and assessing activity by visual examination? A systematic review and meta-analysis.

AIM: To assess the undergraduate students' performance in detecting and staging caries and assessing activity using visual inspection. DESIGN: Two independent reviewers searched the literature through PubMed/MEDLINE, Scopus, Lilacs databases, and OpenSINGLE. Meta-analyses summarized the results concerning reproducibility and accuracy at D1 (considering all lesions) and D3 (including only cavitated lesions or lesions into dentin) levels. For activity, we considered sound surfaces plus inactive caries lesions vs active lesions. Meta-regression assessed the effect of methodological variables on the outcomes. RESULTS: Fourteen studies were included. The mean reproducibility values were ≥0.52, except for interexaminer agreement when assessing caries activity (0.39; 95% CI 0.10-0.67). The intra-examiner reproducibility tended to be higher than the interexaminer reproducibility. Overall, undergraduate students' performance in staging caries lesions using visual examination was good (AUC>0.85 and DOR>25). The sensitivity values were moderate; however, these were associated with excellent specificity values. Despite few pooled studies, caries activity assessment revealed moderate overall performance, with lower pooled sensitivity than pooled specificity. Students' education level and background clinical experience had no influence on the accuracy and reproducibility of the visual inspection. CONCLUSION: Undergraduate students' performance in detecting and staging caries using visual inspection was good, although caries activity assessment still requires improvement.

Dental Students' Performance in Detecting In Vitro Occlusal Carious Lesions Using ICDAS with E-Learning and Digital Learning Strategies.

The aim of this study was to assess the performance of dental students for detecting in vitro occlusal carious lesions using the International Caries Detection and Assessment System (ICDAS) with different learning strategies. A convenience sample of all 64 fourth-year dental students at a dental school in Brazil who had no previous experience with ICDAS was selected for the study in 2015. First, students performed the in vitro examination of the occlusal surfaces of 80 teeth according to ICDAS. Two weeks later, students were randomly allocated to three groups: G1 (n=21), ICDAS e-learning; G2 (n=22), ICDAS e-learning + digital learning tool (DLT); G3 (n=21), no training (control group). All students reexamined the 80 teeth according to ICDAS two weeks later. Sensitivity, specificity, and area under the ROC curve (AUC) were calculated according to three thresholds. Of the 64 students, 59 completed all study phases, for a 92.2% participation rate. The intra-group comparison found significantly higher sensitivity and specificity values for G1 and G2 students. G3 students showed an increased sensitivity at the D2 threshold. G2 was the only training strategy that resulted in significant improvement for the AUC. In the comparison of groups at the same threshold, G1 showed higher specificity at D3 threshold (0.78) than G2 (0.72) and G3 (0.73). Regarding sensitivity, G1 showed a lower value at D2 (0.91) threshold than G2 (0.94) and G3 (0.94). In this study, both training strategies (ICDAS e-learning and ICDAS e-learning + DLT) improved the performance of dental students for the in vitro detection of occlusal carious lesions, mainly when the association of methods was used.

Influence of contact points on the performance of caries detection methods in approximal surfaces of primary molars: an in vivo study.

This in vivo study aimed to evaluate the influence of contact points on the approximal caries detection in primary molars, by comparing the performance of the DIAGNOdent pen and visual-tactile examination after tooth separation to bitewing radiography (BW). A total of 112 children were examined and 33 children were selected. In three periods (a, b, and c), 209 approximal surfaces were examined: (a) examiner 1 performed visual-tactile examination using the Nyvad criteria (EX1); examiner 2 used DIAGNOdent pen (LF1) and took BW; (b) 1 week later, after tooth separation, examiner 1 performed the second visual-tactile examination (EX2) and examiner 2 used DIAGNOdent again (LF2); (c) after tooth exfoliation, surfaces were directly examined using DIAGNOdent (LF3). Teeth were examined by computed microtomography as a reference standard. Analyses were based on diagnostic thresholds: D1: D 0 = health, D 1 ­D 4 = disease; D2: D 0 , D 1 = health, D 2 ­D 4 = disease; D3: D 0 ­D 2 = health, D 3 , D 4 = disease. At D1, the highest sensitivity/specificity were observed for EX1 (1.00)/LF3 (0.68), respectively. At D2, the highest sensitivity/ specificity were observed for LF3 (0.69)/BW (1.00), respectively. At D3, the highest sensitivity/specificity were observed for LF3 (0.78)/EX1, EX2 and BW (1.00). EX1 showed higher accuracy values than LF1, and EX2 showed similar values to LF2. We concluded that the visual-tactile examination showed better results in detecting sound surfaces and approximal caries lesions without tooth separation. However, the effectiveness of approximal caries lesion detection of both methods was increased by the absence of contact points. Therefore, regardless of the method of detection, orthodontic separating elastics should be used as a complementary tool for the diagnosis of approximal noncavitated lesions in primary molars.

Influence of sterilization process on cutting effectiveness andurability of ultrasonic tips / Influência do processo de esterilização na efetividade de corte e durabilidade das pontas ultra-sônicas

Objetivo: O objetivo foi avaliar a influência de diferentes métodos de esterilização na efetividade de corte e durabilidade de pontas ultra-sônicas cilíndricas comparadas com pontas diamantadas cilíndricas convencionais. Material e Métodos:Quinze pontas diamantadas cilindricas (1092)(KG Sorensen) acopladas a um motor de de alta rotação, e quinze pontas ultrassonicas cilíndricas(8,2137) (CVDentus) acopladas a um ultra-som foram utilizadas para realizar preparos cavitários padronizados em fragmentos de dentes bovinos higidos, limpos com taça de borracha, pedra-pomes e água. Após cada um dos 10 preparos, as pontas foram9 vezes esterilizadas em autoclave (SA), estufa (SO), ou limpas com escova, sabão e água (C). Os fragmentos foram pesados e microfotografias das pontas foram tomadas no início e no final do experimento. Outras9 pontas de diamante CVD e 9 convencionais foram submetidos aos mesmos ciclos de esterilização em autoclave (SAC), forno (SOC) ou lavado com água e sabão (CC) no entanto, sem serem usadas para fazer preparos cavitários, servindo como controle. Realizou-se análise descritiva dos valores encontrados na pesagem e dos scores das microfotografias.Resultados: Diferenças estatisticamente significativas(teste t de Student pareado) foram observadas entre as pontas após a esterilização (p = 0,0001). SOe SA não influenciaram na efetividade de corte e durabilidade das pontas diamantadas ultra-sônicas e convencionais. As microfotografias mostraram diferenças morfológicas entre as pontas utilizadas para os preparos e o controle. Conclusão: As esterilizaçoes por autoclave e estufa não influenciaram a efetividade de corte e durabilidade das pontas diamantadas convencionais. Pontas diamantadas convencionais apresentaram maiores alterações estruturais após a realização de preparos cavitários e procedimentos de limpeza / esterilização, independentemente do processo utilizado.

Objectives: The aim was to evaluate influence of different sterilization methods on cutting effectiveness and durability of cylindrical ultrasonic burs compared with conventional cylindrical diamond-coatedburs. Material and Methods: Fifteen conventional cylindrical diamond-coated (1092) (KG Sorensen) coupled to a high-speed turbine, and fifteen cylindrical ultrasonic (8.2137) (CVDentus) burscoupled to an ultrasound-handpiece were used toper form standardized cavity preparations in healthy bovine tooth fragments, cleaned with rubber cup, pumice stone and water. After every 10 preparations, burs were sterilized 9 times in autoclave (SA), oven (SO), or cleaned with brush, soap and water (C). Fragments were weighed and microphotographs of burs were taken at the beginning and end of experiment. Another 9 conventional diamond-coatedand 9 CVD burs under went the same sterilizationcycles in autoclave (SAC), oven (SOC) or washedwith soap and water (CC) however, without beingused for making cavity preparations, serving ascontrol. Descriptive analyses were made of thevalues found by weighing and microphotographyscores. Results: Statistically significant differences (Paired Student’s-t test) were observed among bursafter sterilization (p = 0.0001). SO and SA didnot influence cutting effectiveness and durability of ultrasonic and conventional diamond-coatedburs. The microphotographs showed morphological differences between the burs used for preparation and the control. Conclusion: Sterilization by oven andautoclave did not influence cutting effectiveness and durability of CVD and conventional diamond-coatedburs. Conventional diamond-coated burs presented greater structural alterations after performing cavity preparations and cleaning/sterilization procedures, irrespective of the process used.

The performance of conventional and fluorescence-based methods for occlusal caries detection: an in vivo study with histologic validation.

BACKGROUND: The authors conducted an in vivo study to determine clinical cutoffs for a laser fluorescence (LF) device, an LF pen and a fluorescence camera (FC), as well as to evaluate the clinical performance of these methods and conventional methods in detecting occlusal caries in permanent teeth by using the histologic gold standard for total validation of the sample. METHODS: One trained examiner assessed 105 occlusal surfaces by using the LF device, LF pen, FC, International Caries Detection and Assessment System (ICDAS) criteria and bitewing (BW) radiographic methods. After tooth extraction, the authors assessed the teeth histologically. They determined the optimal clinical cutoffs by means of receiver operating characteristic curve analysis. RESULTS: The specificities and sensitivities for enamel and dentin caries detection versus only dentin caries detection thresholds were 0.60 and 0.93 and 0.77 and 0.52 (ICDAS), 1.00 and 0.29 and 0.97 and 0.44 (BW radiography), 1.00 and 0.85 and 0.77 and 0.81 (LF device), 0.80 and 0.89 and 0.71 and 0.85 (LF pen) and 0.80 and 0.74 and 0.49 and 0.85 (FC), respectively. The accuracy values were higher for ICDAS, the LF device and the LF pen than they were for BW radiography and the FC. CONCLUSIONS: The clinical cutoffs for sound teeth, enamel carious lesions and dentin carious lesions were, respectively, 0 through 4, 5 through 27 and 28 through 99 (LF device); 0 through 4, 5 through 32 and 33 through 99 (LF pen); and 0 through 1.2, 1.3 and 1.4 through 5.0 (FC). The ICDAS, the LF device and the LF pen demonstrated good performance in helping detect occlusal caries in vivo. The ICDAS did not seem to perform as well at the D(3) threshold (histologic scores 3 and 4) as at the D(1) threshold (histologic scores 1-4). BW radiography and the FC had the lowest performances in helping detect lesions at the D(1) and D(3) thresholds, respectively. CLINICAL IMPLICATIONS: Occlusal caries detection should be based primarily on visual inspection. Fluorescence-based methods may be used to provide a second opinion in clinical practice.

Comparison among gold standard techniques used for the validation of methods for occlusal caries detection.

UNLABELLED: The aim of this in vitro study was to assess the agreement among four techniques used as gold standard for the validation of methods for occlusal caries detection. Sixty-five human permanent molars were selected and one site in each occlusal surface was chosen as the test site. The teeth were cut and prepared according to each technique: stereomicroscopy without coloring (1), dye enhancement with rhodamine B (2) and fuchsine/acetic light green (3), and semi-quantitative microradiography (4). Digital photographs from each prepared tooth were assessed by three examiners for caries extension. Weighted kappa, as well as Friedman's test with multiple comparisons, was performed to compare all techniques and verify statistical significant differences. RESULTS: kappa values varied from 0.62 to 0.78, the latter being found by both dye enhancement methods. Friedman's test showed statistical significant difference (P < 0.001) and multiple comparison identified these differences among all techniques, except between both dye enhancement methods (rhodamine B and fuchsine/acetic light green). Cross-tabulation showed that the stereomicroscopy overscored the lesions. Both dye enhancement methods showed a good agreement, while stereomicroscopy overscored the lesions. Furthermore, the outcome of caries diagnostic tests may be influenced by the validation method applied. Dye enhancement methods seem to be reliable as gold standard methods.

Dental erosion and salivary flow rate in cerebral palsy individuals with gastroesophageal reflux.

BACKGROUND: A high prevalence of gastroesophageal reflux (GERD) has been observed in individuals with cerebral palsy (CP). One of the main risks for dental erosion is GERD. This study aimed to evaluate the presence of GERD, variables related to dental erosion and associated with GERD (diet consumption, gastrointestinal symptoms, bruxism), and salivary flow rate, in a group of 46 non-institutionalized CP individuals aged from 3 to 13 years. METHODS: Twenty CP individuals with gastroesophageal reflux (GERDG) and 26 without gastroesophageal reflux (CG) were examined according to dental erosion criteria, drinking habits, presence of bruxism, and salivary flow rate. A face-to-face detailed questionnaire with the consumption and frequency of acid drinks, gastrointestinal symptoms (regurgitation and heart burn), and the presence of bruxism were answered by the caregivers of both groups. Unstimulated whole saliva was collected under slight suction, and salivary flow rate (ml/min) was calculated. RESULTS: The GERDG presented higher percentages of younger quadriplegics individuals compared to CG. The presence of regurgitation, heart burn, and tooth erosion (Grade 1) was significantly more prevalent in GERDG. It was observed difference in the salivary flow rate between the studied groups. On logistic multivariate regression analysis, the unique variable independently associated with the presence of GERD was dental erosion (P = 0.012, OR 86.64). CONCLUSION: The presence of GERD contributes significantly to dental erosion in the most compromised individuals with quadriplegics cerebral palsy individuals, increasing the risk of oral disease in this population.

Light-emitting diode and laser fluorescence-based devices in detecting occlusal caries.

The aim of this study was to assess the performance of two light-emitting diode (LED)- and two laser fluorescence-based devices in detecting occlusal caries in vitro. Ninety-seven permanent molars were assessed twice by two examiners using two LED- (Midwest Caries - MID and VistaProof - VP) and two laser fluorescence-based (DIAGNOdent 2095 - LF and DIAGNOdent pen 2190 - LFpen) devices. After measuring, the teeth were histologically prepared and classified according to lesion extension. At D1 the specificities were 0.76 (LF and LFpen), 0.94 (MID), and 0.70 (VP); the sensitivities were 0.70 (LF), 0.62 (LFpen), 0.31 (MID), and 0.75 (VP). At D(3) threshold the specificities were 0.88 (LF), 0.87 (LFpen), 0.90 (MID), and 0.70 (VP); the sensitivities were 0.63 (LF and LFpen), 0.70 (MID), and 0.96 (VP). Spearman's rank correlations with histology were 0.56 (LF), 0.51 (LFpen), 0.55 (MID), and 0.58 (VP). Inter- and intraexaminer ICC values were high and varied from 0.83 to 0.90. Both LF devices seemed to be useful auxiliary tools to the conventional methods, presenting good reproducibility and better accuracy at D(3) threshold. MID was not able to differentiate sound surfaces from enamel caries and VP still needs improvement on the cut-off limits for its use.

In vitro detection of secondary caries associated with composite restorations on approximal surfaces using laser fluorescence.

This study evaluated the performance of the DIAGNOdent pen laser fluorescence device (LFpen) in comparison with visual examination (VE), bitewing radiographs (BW) and visual examination combined with bitewing radiographs (VEBW) in detecting secondary approximal caries associated with composite restorations. In total, 60 approximal surfaces from 43 permanent molars with composite restorations were assessed twice by two examiners using the LFpen, VE, BW and VEBW. After histological preparation and hardness measurements, the sample was assigned to either a crown or root caries group, depending on the location of the lesions as the gold standard. For crown caries at D1, the highest values of specificity and sensitivity were observed for the LFpen at a cutoff value of 18 (1.00) and for the VEBW (0.89). At D3 (cutoff of 30), the LFpen showed the highest values of sensitivity and specificity. For root caries, the LFpen and VEBW showed the highest values of specificity (0.54), sensitivity (0.81) and accuracy (0.69). The Spearman rank correlation coefficients for crown/root caries with histology were 0.54/0.37 (LFpen), 0.29/0.10 (BW), 0.29/0.18 (VE) and 0.23/0.37 (VEBW). For the LFpen, the ICC varied from 0.80 (interexaminer) to 0.97 (intraexaminer B); the kappa value was 0.19 for BW and 0.35 for VE (interexaminer). Intraexaminer kappa values for BW were 0.25 (A) and 0.29 (B), and those for VE were 0.31 (A) and 0.32 (B). The LFpen device exhibited a performance comparable to that of conventional methods but with higher interexaminer reproducibility. Therefore, the LFpen should be considered an auxiliary method for the detection of secondary approximal caries associated with composite restorations.

Relationship between DIAGNOdent values and sealant penetration depth on occlusal fissures.

The aim of this in vitro study was to evaluate the relationship between laser fluorescence values and sealant penetration depth on occlusal fissures. One hundred and sixty-six permanent molars were selected and divided into four groups, which were each treated using a different sealant (two clear and two opaque). The teeth were independently measured twice by two experienced dentists using two laser fluorescence devices-DIAGNOdent (LF and LFpen)-before and after sealing, and then thermoclycled. After measuring, the teeth were histologically prepared and assessed for caries extension. Digital photographs of the cut sealed sites were assessed, and the sealant penetration depth was measured. All 166 sites were measured by one of the examiners taking as limits the outer and inner surface of the sealant into the fissure. For each device (LF and LFpen) and each group, the difference between the values at baseline and after sealing was plotted against the sealant penetration depth and scatter plots were provided. It could be observed that most of the points were concentrated around the zero line, for both LF and LFpen in the four groups. In conclusion, there is no relation between changes in DIAGNOdent values and increasing of depth sealant penetration within the occlusal fissures.

In vitro comparison of laser fluorescence performance with visual examination for detection of occlusal caries in permanent and primary molars.

The aim of this study was to compare the performance of the DIAGNOdent 2095 with visual examination for occlusal caries detection in permanent and primary molars. The sample comprised 148 permanent human molars and 179 primary human molars. The samples were measured and visually examined three times by two examiners. After measurement, the teeth were histologically prepared and assessed for caries extension. Sensitivity, specificity, accuracy and area under the receiver operating characteristics (ROC) curve were calculated. Intra-class correlation (ICC), unweighted kappa and the Bland and Altman method were used to assess inter- and intra-examiner reproducibility. DIAGNOdent showed higher specificity and lower sensitivity than did visual examination. The ICC values indicated an excellent agreement between the examinations. Kappa values varied from good to excellent for DIAGNOdent but from poor to good for visual examination. In conclusion, the DIAGNOdent may be a useful adjunct to conventional methods for occlusal caries detection.