Caries Incidence in a Healthy Young Adult Population in Relation to Diet.

In the past, epidemiological studies focused on cavitated stages of caries. The arrival of the International Caries Detection and Assessment System (ICDAS) in 2004 allowed for clinical measurements of the initial stages of enamel caries. However, since the introduction, most studies applying the ICDAS still have studied the diseased population. The objective of this cross-sectional observational study was to describe early enamel caries in a large healthy young adult population and determine the relationship with diet and oral hygiene measures. The study population consisted of 268 healthy participants without frank cavitation. The examinations were done visually and radiographically using ICDAS on all tooth surfaces. In total, 8.6% of the surfaces (occlusal > approximal > smooth) had caries, of which 92.0% were confined to enamel (28.5% ICDAS score 1, 54.0% score 2, 8.6% score 3). Thirteen percent of the occlusal and 63% of the approximal caries were found with radiography. Thus, radiography is quintessential for the diagnosis of approximal enamel lesions. We found a positive correlation between enamel caries (ICDAS 1 to 3) and the consumption of mono- and disaccharides and carbohydrates ( r = 0.226 and r = 0.188, respectively, both P < 0.01), as well as a negative correlation with alcohol consumption ( r = -0.202, P < 0.01). There was also a positive correlation between enamel caries and the energy intake from mono- and disaccharides (sugar kJ, r = 0.206, P < 0.01), which was independent of body mass index. Only 11 participants consumed less than 10% of total energy as sugar kJ, which is the recommended percentage of kJ from free sugar by the World Health Organization. No clear correlation was found with oral hygiene. In conclusion, in this healthy young adult population, caries was found in 97.8% of the subjects, mostly initial enamel caries (ICDAS 1 to 2) in the occlusal surface of molars, and was related with dietary factors.

Declining Caries Trends: Are We Satisfied?

WHO data suggest that all over the world the prevalence of caries has declined at the end of the previous and in the first decade of the present century. This decline started wherever the use of effective fluoride toothpaste became commonplace. Even though the decline is considerable with a 90 % reduction in DMFT for 12-year-olds in Western Europe and the USA, caries still affects 60-90 % of the children throughout the world. In the high- and middle-income countries, the nature of caries has changed from a rapid progressing disease of childhood to a slowly progressing disease throughout adulthood and even old age. However, throughout the world, the circumstances for caries differ, e.g., low-income countries experience more caries with higher sugar consumption, while between high-income countries this correlation is reversed. In high-income countries, fluoride is widely used and preventive programs in dental offices are in place. These programs, if effective, may not be a realistic option in low-income countries. In order to reduce caries in the world even further, the use of effective and affordable fluoride toothpaste should be encouraged and enabled.

Use of the ICDAS system and two fluorescence-based intraoral devices for examination of occlusal surfaces.

AIM: The aims of this study were to assess the inter-examiner reliability of ICDAS and Soprolife intra-oral camera ex vivo using 5 examiners and to compare in vivo the validity of two fluorescence-based intra-oral devices in examining occlusal surfaces with early carious lesions. MATERIALS AND METHODS: Thirty-seven occlusal surfaces of posterior primary and permanent teeth of 20 children were examined using Diagnodent pen (KaVo, Biberach/Riß, Germany) and Soprolife (Acteon Group, La Ciotat, France) fluorescence intra-oral camera. The white light photos, made by Soprolife camera, were evaluated using ICDAS scores and the Soprolife fluorescence photos were scored as sound, enamel caries and dentine caries by 5 experienced dentists. The dentists were trained for the use of ICDAS system with a short online training programme (ICDAS.org) and for the scoring of caries on the fluorescence images with example images. STATISTICS: cut-offs were made for ICDAS, Soprolife and Diagnodent to distinguish sound surfaces and enamel caries from dentinal caries. The inter-examiner reliability was calculated using intra-class correlation coefficient. RESULTS: On white light images the examiners found 16 enamel caries and 21 dentine caries with the ICDAS system. On the Soprolife fluorescent images 24 enamel lesions, 9 dentine lesions and 4 sound surfaces were observed. The inter-examiner reliability (ICC) of the ICDAS system on white light photographs and of Soprolife on the fluorescent images for average measures was 0.70 and 0.72, respectively. The sensitivity and specificity of Soprolife (95%CI) was 0.43 and 1.0 respectively, using ICDAS as a reference standard. The sensitivity and specificity of Diagnodent (95%CI) was 0.62 and 0.81 respectively. CONCLUSION: A short training of dentists in the use the ICDAS system resulted in satisfactory inter-examiner reliability for the analysis of occlusal lesions on white light images. Soprolife and Diagnodent do not contribute to a better detection of early carious lesions.

Evaluation of the appreciation of virtual teeth with and without pathology.

AIM: Virtual teeth with and without tooth pathology have been developed for use in a virtual learning environment in dental education. The objective of this study was to evaluate the appearance of these virtual teeth for use in dental education and to compare them with contemporary educational models, such as plastic teeth (Frasaco GmbH) and extracted human teeth. MATERIAL AND METHODS: Six sets of photographs representing six different teeth were shown to dentists, teachers (dentists) and dental students (bachelor's and master's degree students). Each set consisted of 15 pictures showing five views of the extracted human tooth, the similar virtual tooth and the plastic tooth. The five views represented the mesial, distal, occlusal, buccal and lingual surfaces. The virtual tooth was the same as the extracted tooth (scanned with a cone beam CT, coloured and edited in ColorMapEditor(®) ), and the plastic tooth presented the best possible match to the extracted tooth. The participants were asked to rate the appearance of the virtual teeth (overall and in terms of caries, restoration and colours), whether the virtual or plastic teeth resembled the extracted teeth better and from which teeth they expected to learn the most (extracted, virtual or plastic). RESULTS: Each group of participants found that the virtual teeth resembled the extracted teeth more than they resembled the plastic teeth; 71% of the participants expected to learn more from the virtual teeth than from the plastic teeth. CONCLUSION: The results show that the appearance of the virtual teeth was considered more realistic than the appearance of the plastic teeth. The expectation was that the learning opportunities of the virtual teeth are better than of the plastic teeth.

Prevention of erosion and abrasion by a high fluoride concentration gel applied at high frequencies.

The aim of this study was to determine maximum attainable protection of enamel from erosion and erosion abrasion using a highly fluoridated gel with and without additional fluoride from toothpaste. Thirty-six bovine enamel specimens were subjected to six erosive attacks per day (1% citric acid with pH 2.3 for 30 s), while the rest of the day the specimens were in artificial saliva. There were four treatment groups (9 specimens in each group): fluoride-free toothpaste/saliva slurry twice daily (group T0), fluoride-containing toothpaste/saliva slurry twice daily using 1,250 ppm F toothpaste (group TF), fluoride-containing toothpaste/saliva slurry twice per day plus application of a highly fluoridated gel (12,500 ppm F) twice a day for 120 s (group 2F) and a group with gel application 8 times a day (group 8F). Additionally, half of each specimen in all groups was subjected to brushing abrasion during application of the toothpaste/saliva slurry. Brushing abrasion alone led to no observable enamel loss measured with profilometry. After 14 days of cycling of erosion without toothbrushing abrasion, high-fluoride gel application 2 or 8 times daily showed significantly less enamel loss (median 24/19 microm) than with toothpaste with or without fluoride (41/45 microm). After 14 days of cycling of erosion and toothbrushing abrasion, gel application 2 or 8 times daily (33/29 microm) showed significantly less enamel loss than toothpaste with or without fluoride (57/62 microm). We conclude that a highly fluoridated acidic gel is able to protect enamel from erosion and toothbrushing abrasion while fluoridated tooth paste provides little protection.

Acid susceptibility at various depths of pH-cycled enamel and dentine specimens.

pH-cycling and in situ studies have shown that fluctuations in de-/remineralisation conditions or in fluoride usage can lead to laminations inside enamel or dentine lesions. Layers with different mineral content are thought to reflect the history of fluoride administrations. Studying the dissolution properties of such lesions at various depths -- using bulk specimens -- is presumably hampered by limited diffusion of acids through the lesion pores. Therefore, in this study the acid susceptibility of enamel and dentine lesions and the underlying sound tissues was studied by exposing sections to acid buffers from the cut rather than from the external surface. Specimens were obtained from a previous study of the effects of high-fluoride (0, 1,000, 2,000, 3,000/5,000 ppm F) toothpastes on enamel and dentine de-/remineralisation. Sections were subjected to acid buffers for 3 and 7 days and the changes in mineral content were monitored by contact microradiography. For enamel lesions a significant difference in dissolution over depth was observed between the groups subjected to the different fluoride schemes. At 7 days a dose response was found between the different fluoride groups and the lesion parameters. In the no-fluoride group dissolution in the original lesion and the sound tissue were similar. All dentine lesions which had been treated with fluoride showed inhibition of dissolution, but the inhibition did not increase with higher fluoride concentrations. Deeper into the dentine tissue there was some protection, but it was not statistically significant. We conclude that penetration of fluoride through the lesion pores determines the dissolution pattern of a lesion at various depths.

Thickness measurement of worn molar cusps by ultrasound.

This study aimed to evaluate the effectiveness of an ultrasonic system for in vitro measurement of cusp tips of human teeth. Each worn cusp of 12 molar teeth was measured with an industrial ultrasonic system. The teeth were sectioned and measured by polarized light microscopy. The ultrasonic measurements and histological readings were moderately correlated (r = 0.601, p < 0.01). The ultrasonic system used in this study seemed a promising method for measuring thickness of worn cusp tips of extracted human molar teeth.

Caries prevalence measured with QLF after treatment with fixed orthodontic appliances: influencing factors.

Caries prevalence on the buccal surfaces of teeth in orthodontic patients was determined with QLF and visual examination immediately after removal of fixed appliances. The number of lesions found by QLF far outnumbered that found by visual examination, but the distribution pattern was similar. 97% of all subjects and on average 30% of the buccal surfaces in a person were affected. On average, in males 40% of surfaces and in females 22% showed white spots (p < 0.01). Caries prevalence was lower (p < 0.01) in incisors and cuspids than in molars and premolars. A positive correlation with caries prevalence was found for the bleeding scores 6 weeks after debonding and lactobacillus counts before debonding. Mutans streptococci counts, age, treatment duration, socioeconomic status and dietary habits showed no correlation with caries prevalence.

Remineralisation of enamel lesions with daily applications of a high-concentration fluoride gel and a fluoridated toothpaste: an in situ study.

The inhibition of enamel demineralisation and the enhancement of remineralisation are positively but not linearly related to the concentration of fluoride, especially when high fluoride concentrations are used. The aim of this in situ experiment was to determine the maximum amount of enamel remineralisation that can be achieved with daily applications of very high concentrations of fluoride. For this purpose we compared the efficacy of a daily application of fluoridated topical gel (12500 ppm F, partly as NaF, Olafluor and Dectafluor, pH 4.5) in combination with a fluoridated toothpaste (1450 ppm F as NaF), with fluoridated toothpaste alone. Participants (n = 26, with partial dentures) were fitted with a demineralised enamel specimen (mean mineral loss of 1674 vol%.micro m) and were instructed to use one of the two fluoride treatments. After 4 weeks of treatment, the specimens were retrieved, a section was cut and analysed with microradiography. The remainder of each of the specimens was used for analysis of the 'loosely bound' and 'bound' fluoride. Fluoride was measured with gas-liquid chromatography. After 4 weeks in the mouth, the original lesion was reduced in size by 54% in the toothpaste + gel group (n = 14) and by 44% in the toothpaste-only group (n = 12), but the difference between the groups was not statistically significant. The mineral content profiles showed remineralisation of the lesions throughout the depth of the lesion. The enhancement of remineralisation by the high amounts of fluoride was most pronounced in the surface layer. For both the 'loosely bound' and 'bound' fluoride, a statistically significant increase in fluoride concentration could be found in the toothpaste + gel group. In the 4-week in situ period the use of high amounts of fluoride resulted in a maximum remineralisation rate. This is illustrated by an increase in remineralisation and higher fluoride concentrations in the toothpaste + gel group compared to the toothpaste-only group.

Effect of a solution with high fluoride concentration on remineralization of shallow and deep root surface caries in vitro.

A root dentin single-section model was developed to compare the efficacy of different fluoride treatments on the remineralization of lesions. Shallow ( approximately 170 microm) and deep ( approximately 400 microm) lesions were produced in acetic acid buffer solutions (pH 5.0) with 0.1- and 0.5-ppm fluoride for 3 days and 2 weeks, respectively. Next, the sections were pH-cycled for 4 weeks. Following the pH cycling, all sections were first remineralized for 5 weeks, then subjected to 10 days of demineralization. The treatments were (1) no treatment (control), (2) daily 1,450-ppm NaF toothpaste, (3) weekly 4,000-ppm fluoride solution, (4) a combination of treatments 2 and 3. In the shallow lesions, the 4,000-ppm fluoride solution and the combination treatment enhanced mineral deposition at the lesion front, producing a second, slightly hyperremineralized layer. Similarly, in the deep lesions a second remineralized layer was detected. In all lesions, the fluoride solution treatment showed significantly more remineralization compared to the control and the toothpaste treatment (p<0.05), most of which was formed during the pH cycling. In the demineralization period, the control showed significantly higher mineral loss than all other treatments. These results indicate that a 4,000-ppm fluoride solution might be effective for remineralization of root dentin lesions even over 400 microm depth.

The validity and repeatability of three light-induced fluorescence systems: An in vitro study.

New optical systems are being developed that aim to determine the extent of demineralization in enamel. In our laboratory we have compared three such systems: a ring illuminator equipped with a laser, a beam splitter also equipped with a laser and an intra-oral camera equipped with a white-light arc lamp. The aim of the study was to compare the ability of the different optical systems to detect small enamel lesions with microradiographic analysis and to determine the repeatability of these systems. Forty human enamel specimens (3mm in diameter) were mounted in acrylic and polished. The specimens were kept moist throughout the study. Each specimen of the four groups was individually exposed to 14 ml of Carbopol demineralizing solution for 24, 48, 72 and 96 h, respectively. The mineral loss of the 40 specimens was assessed with blue-violet light- induced fluorescence. Each image was captured with a video camera and analysed with dedicated software. The measurements were repeated 3 times with complete shut-down of the system in between the measurements. The same measurements were performed with the ring illuminator, the beam splitter and the arc lamp. The specimens were then cut into thin sections and analysed with microradiography. Similar high correlations between microradiography and the light-based analysis systems were found for the beam splitter and the clinical caries camera set-up. The repeatability was best for the beam splitter set-up. This indicates that the light-induced fluorescence measurement technique can be used in different configurations and that the repeatability of the measurements is influenced by the physical stability of the set-up.

Effect of a fluoridated toothpaste on lesion development in plaque-filled dentine grooves: an intra-oral study.

Fluoride can inhibit caries at plaque-retention sites, but some studies indicate that fluoride is less effective in fissures than on smooth surfaces. To study the efficacy of fluoridated toothpastes at plaque-retention sites, an intra-oral model was used with bovine coronal dentine discs, in which grooves of two different widths were sawn. The discs were mounted in the partial prostheses of 31 participants divided into two groups. One group brushed with a non-fluoridated toothpaste and a second with a paste containing 1,000 ppm fluoride as NaF. After 3 months, the specimens were retrieved and from each a thin section was taken for microradiographic analysis. Lesions which developed in the grooves resembled natural lesions in terms of the presence of a surface layer and the mineral content profiles. Extensive lesions followed the direction of the dentinal tubules. The mineral loss was quantified half-way into and at the base of the grooves and ranged from 0 to 20,000 vol% x microns. Analysis of variance showed that the mineral loss was significantly influenced by the treatment and the width of the grooves (p < 0.001). In the broad grooves the average mineral loss was 19% smaller in the fluoride group than in the non-fluoride group, in the narrow grooves this value was 7%. Taking the two treatment groups together, the average mineral loss was largest half-way into the broad grooves (4,921 vol% x microns) and smallest at the base of the narrow grooves (2,289 vol% x microns). The results with this new intra-oral model indicate that the dimensions of small grooves in dentine, and thus their accessibility, determine not only their susceptibility to caries but also the protective effect of a fluoridated toothpaste.

The effect of a fluoridated toothpaste on dentinal lesions in plaque-filled grooves: an intra-oral crossover study.

Recently, we introduced an intra-oral dentin demineralization model to evaluate the efficacy of a fluoridated toothpaste at plaque-retention sites with limited access to salivary components and fluoride. Usage of the fluoridated toothpaste reduced mineral loss from grooves in sound dentin by 15% compared with a non-fluoridated toothpaste (Lagerweij et al., 1997). In the current study, preformed dentinal lesions were subjected to similar toothpaste treatments. To improve the power of the model in discriminating between toothpaste groups, we changed the design from monadic to crossover to reduce the influence of variation between the participants. Two sets of specimens were placed in the partial prostheses of 29 participants who used a toothpaste containing either 1000 ppm fluoride or no fluoride during two consecutive six-week periods. Changes in mineral content were analyzed by transverse microradiography. The average mineral loss after the non-fluoride period was 1785 vol% x micron (SD 2399), and 1335 vol% x micron (SD 2039) after the fluoride period, a 25% inhibition in demineralization. Analysis of variance showed that the demineralization was significantly influenced not only by the type of treatment (p < 0.001 level), but also by the participant (p < 0.001), the width of the groove (p < 0.001), and the depth into the groove where changes in mineral content were measured (p < 0.017). Twenty-one percent of all the lesions showed remineralization. No significant difference in the extent or the occurrence of remineralization was found between the treatments.

Demineralization of dentine grooves in vitro.

Caries mainly occurs at retention sites for plaque such as pits, fissures, margins of restorations and interproximal sites. An in vitro model was developed to investigate dentine caries in narrow gaps. Forty bovine coronal dentine discs were covered with bonding agent. In 20 discs, two grooves, 200 and 340 mu m wide and 500 mu m deep, were sawn to mimic fissures. In the 20 other discs, a 1-mm-wide groove was made and, after polyester sheets were placed against both walls, filled with composite. After curing of the composite and removal of the sheets, grooves of 22 mu m remained at the borders of the restoration. All grooves were exposed to 8% methylcellulose gel 0.1 M lactic acid at pH 4.8 for 1 week. Demineralization was determined by microradiography of sections sawn out of the center of the discs. The walls of the grooves showed subsurface lesions, which decreased in size towards the base of the grooves. The average mineral losses (vol % x mu m) at the entrance of the 22-, 200- and 340-mu m-wide grooves were 1,112 (SD 370), 1,277 (293) and 1,277 (255), halfway down the groove 218 (150), 659 (244) and 797 (207) and at the base of the groove 140 (88), 285 (145) and 504 (205), respectively. Analysis of variance and Tukey's B test showed that the average mineral losses from grooves of different width and from sites at different depth were all significantly different at p<0.05 level, but not for the mineral losses from the entrance of the two wider grooves and from the two lower sites in the narrowest groove. The reduced mineral loss in the two narrower groove widths is assumed to be caused by the more limited inward diffusion of acids and outward diffusion of mineral ions through the methylcellulose gel.

The video camera compared with the densitometer as a scanning device for microradiography.

In the recent past image analysis systems, comprising a video (CCD) camera and dedicated software, have replaced densitometer-based systems to analyze mineral content profiles using transversal microradiography (TMR). The main reasons for the introduction of the CCD camera were the ease and speed at which it can be operated. The densitometer, as a scanning device for TMR, has in the recent years been validated and is in this study considered as 'gold standard'. Comparisons of the two scanning devices for measuring the optical density of microradiograms have never been reported in the literature. The focus of this study was on accuracy and reproducibility of the scanning devices with the emphasis put on possible limitations of the CCD camera relative to the densitometer. These include resolution, number of gray levels and homogeneity of illumination of the scan area. The microscope was arranged in such a way that the same area on the microradiogram could be assessed by both scanning devices. Three different types of lesions were analyzed: a subsurface lesion, a surface-softened lesion and a laminated lesion. Paired t tests showed no significant difference between the mineral content profiles produced by the two scanning devices. The integrated mineral loss values were calculated and compared with analysis of variance and showed no significant differences. It is therefore concluded that mineral content profiles and integrated mineral loss obtained by the CCD camera are as accurate and reproducible as those obtained by the densitometer.