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RESEARCH

ABSTRACT

Early treatment of incipient carious lesions

A two-year clinical evaluation

JAMES C. HAMILTON, D.D.S.; JOSEPH B. DENNISON, D.D.S., M.S.; KENNETH W. STOFFERS, D.M.D., M.S.; WILLIAM A. GREGORY, D.D.S., M.S.; KATHLEEN B. WELCH, M.P.H., M.S.

  • M any dental practitioners use dental air abrasion when treating small carious lesions. 1,2 Air abrasion also has been rec- ommended to aid in the diagnosis of ques- tionable pit and fissure lesions. 3-5 It would

seem that the earlier a carious lesion is treated, the

smaller the preparation is and the more tooth structure that can be conserved. The potential advantages of early treatment with air abrasion include the conservation of

tooth structure, treatment of small carious lesions without the need for local anesthetic 5-7 and the ability to create small preparations without the noise and vibra- tion of a high-speed rotary handpiece.

A disadvantage of early operative

After two years, tooth structure was not conserved as a result of early treatment of questionable carious lesions in posterior teeth.

intervention is the elimination of the

potential for small incipient lesions to remineralize or arrest such that they do not need operative intervention. Resin- based composites, which most often are used to restore air-abraded teeth, require the use of a bonding agent for optimal results. 8,9 Currently used bonding agents and resin-based compos- ites are subject to technical considera- tions such as moisture control, pooling of the low-viscosity agents and adequate

light curing. This is problematic when treating posterior teeth in particular and can lead to a more technically challenging procedure. In addition, once restored, these teeth require continuing mainte-

nance, 10,11 because of possible wear, microleakage or frac- ture of the restorative material.

Background. The purpose of this study was to quantify conservation of tooth struc- ture and evaluate the efficacy of early treat- ment of questionable carious lesions in pits and fissures of posterior teeth using air abrasion followed by placement of preven- tive resin restorations. Methods. Ninety-three patients with 223 questionably carious teeth, mainly with darkly stained pits and fissures, were recruited from general dentistry clinics. After baseline evaluation, each tooth was randomly assigned to either an early treat- ment or control group. The authors used air abrasion to investigate the pits and fissures of teeth in the early treatment group. The teeth were sealed and restored with a flow- able resin-based composite. All teeth in both groups were examined at six-month intervals to clinically evaluate the quality of the restorations and the caries status of the control teeth. Results. After two years, two of the 113 restorations in the early treatment group required further treatment because of pene- trating stain at a margin. In the control group, 14 teeth required treatment because of caries. The mean weight of the impres- sion material—a surrogate measure of volume of removed tooth structure—in preparations that extended into dentin in the early treatment group was 0.0260 grams compared with 0.0281 g in the con- trol group. There was no statistically sig- nificant difference between the impression weights (P = .390). Conclusion. After two years of a pro- posed five-year study, the authors con- cluded that conservation of tooth structure was not substantiated by early treatment. Clinical Implications. Treating ques- tionable carious lesions early may not con- serve tooth structure.

Given that there are advantages and disadvantages associated with the early treatment of small, questionable carious lesions, we initiated a randomized con- trolled clinical study to investigate the merits of early treatment of these lesions. Although the application of pit

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RESEARCH

and fissure sealants would be appropriate for teeth in all but the oldest patients in this study, we did not use sealants because the hypothesis to be investigated was the effect of early treatment of questionable carious lesions, not preventive measures to control the progression of these lesions. This report will review the two-year results of a proposed five-year study.

PATIENTS, MATERIALS AND METHODS

Before we recruited patients for this clinical study, the Institutional Review Board of the Uni- versity of Michigan, Ann Arbor, examined and approved the protocol, as well as the consent and assent forms. The assent form, which is similar to a consent form, but written at a level to be under- stood by the youngest patients, was required to be signed by minors enrolled in the study. In addi- tion, the consent form was signed by parents or guardians. New and returning patients between the ages of 12 and 36 years were recruited from patients who received a routine dental examination at the University of Michigan School of Dentistry and had at least one questionable carious lesion in any of the pits and fissures of a posterior tooth. We made no distinction between pits or fissures on the buccal or lingual surfaces of the tooth. The diagnosis of questionablewas made by dentists who were supervising dental students, but who were not part of the clinical study. Patients were asked if they would be willing to participate in a clinical study to investigate the early treatment of very small carious lesions. If a patient indicated interest, he or she filled out a referral card that was given to the research coor- dinator (who was not a dentist) to schedule a baseline examination. We kept no records of patients who declined to participate. We defined questionableas no frank caries detected by conventional examination (that is, softness, decalcification or cavitation at the base of a pit or fissure, or evidence of radiolucency seen on bitewing radiographs, which were available for all patients), but we were uncertain about whether caries was present when deep staining or explorer retention was observed. The vast majority of these questionable lesions were darkly stained pits and fissures. We enrolled a maximum of three teeth from each patient to increase the variability of caries risk and to limit the number of teeth lost to follow-up if a patient missed a recall evaluation.

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Although not a requirement for selection, all enrolled teeth were in occlusion with natural dentition. Patients were excluded from the study if they had five or more active carious lesions, which is an indication of high caries risk or significant oral health neglect that could influence the rate of caries development independently of the pit or fis- sure defect. We also excluded patients with a physical or mental handicap that would limit oral hygiene practices or predispose them to an unusually high caries risk. Although these exclu- sion criteria were placed in the protocol to limit the risk to patients enrolled in the study, no patients with questionable carious lesions were excluded owing to these restrictions. Ninety-three patients with 223 questionable carious lesions were enrolled in the study. Each enrolled tooth was examined independently by two dentists who were selected from three of us (J.H., J.D., K.S.) based on our availability at the time of the baseline evaluations. We all used air from an air-water syringe, no. 13-14 explorers purchased and used only for this study, and ×2.5 magnification to examine the study teeth. Each of the dentist examiners had a minimum of 25 years of clinical experience. Each dentist probed the pits and fissures of each study tooth extensively. Each dentist evalu- ated the darkest color of the pit and fissure system, explorer retention in a pit or fissure and gingival health using the Löe and Silness Gin- gival Health Index. 12 One examiner scored the amount of plaque on each study tooth using the Simplified Oral Hygiene Index. 13 Box 1 shows the evaluation criteria. Either of the two examining dentists took 35-millimeter slides of the teeth at a magnifica- tion of ×1.5. Impressions of the occlusal surface of the study teeth were fabricated using a clear polyvinyl siloxane bite registration material. To determine the history or prevalence of dental caries in each patient, we recorded a decayed, missing and filled surfaces, or DMFS, index, as defined by the World Health Organization, 14 at baseline and yearly thereafter. This DMFS score for each patient was linked to each treatment or control tooth in that patient. The mean DMFS scores for the treatment and control groups were calculated by averaging the linked scores for each tooth in the two groups. Erupted third molars were included in the DMFS score for the few patients who had them. None of

Copyright ©2002 American Dental Association. All rights reserved.

the teeth with questionable carious lesions were partially erupted. After all baseline measure- ments were completed, each tooth was randomly assigned to an early treatment group or the con- trol group based on a table of random numbers. 15 Patients with teeth assigned to the early treat- ment group were told that although local anes- thetic usually was not necessary when treating small lesions with air abrasion, the operator would be willing to administer it at any time if the patient desired. With the patients concur- rence, all air-abrasion procedures were initiated without the injection of local anesthetic. Air abrasion. After application of a rubber dam, the dentist air-abraded the questionable pits and fissures of the 113 teeth randomized into the early treatment group using 27-micrometer aluminum oxide powder starting at 80 pounds per square inch (5.8 kilograms per square centi- meter). If the completed preparation extended into dentinan evaluation made independently by the two dentistsan impression was taken to measure the lost tooth structure. Using the impression of the occlusal surface taken during the baseline examination to form the occlusal sur- face of the preparation impression, the dentist injected a quick-setting polyvinyl siloxane low- viscosity impression material into the prepara- tion. The impression was weighed as a surrogate measure of the amount of tooth structure lost. All teeth with preparations that extended into dentin and those with preparations that extended only into enamel were restored or sealed with a flowable light-cured resin-based composite (Tetric Flow, Ivoclar Vivadent Inc., Schaan, Liechten- stein). Every tooth in the treatment group received at least a prepared sealant (that is, for those preparations that were entirely within enamel). We believed that a lightly filled resin would be more appropriate for sealing these narrow enamel-only preparations. If the preparation extended into dentin, the dentist placed a preventive resin restoration with the radiating fissures sealed, using air abrasion and sealing with a flowable resin-based com- posite. This was done according to the manufac- turers instructions (that is, etching with phos- phoric acid gel for 20 seconds, rinsing with water for 15 seconds and applying two light-cured coats of bonding agent [Syntac SC, Ivoclar Vivadent Inc.]). Finishing and polishing were performed using slow-speed burs and rubber points. Recall examinations. Two of the four dentist

BOX 1

RESEARCH

EVALUATION CRITERIA AT BASELINE AND RECALL EXAMINATIONS.*

 
 

GINGIVAL HEALTH

A

Normal

B

Marginal gingivitis

C

 

Chronic gingivitis

 
 

PLAQUE INDEX

0

No plaque visible

1

Film of plaque visible only with periodontal

 

probe

2

Moderate amount of soft deposits visible

3

Abundant amount of soft deposits visible

 
 
 

PIT AND FISSURE COLOR

A

Tooth colored

B

Yellow/orange

C

Light brown

D

Dark brown

E

Black

 
 

PIT AND FISSURE FEEL

A

No stick

B

Slight stick

 

C

Resistance to removal

 
 

CARIES

 

Yes

Caries present

 

No `

Caries absent

 

* If a tooth is treated, the pit and fissure color and feel are re-

 
 

placed with the restorative evaluation criteria shown in Box 2.

 

Source: Löe and Silness. 12 Source: Greene and Vermillion. 13

 

authors re-examined the 113 treated teeth and 110 control teeth at six-month intervals. Although bitewing radiographs were obtained at yearly intervals as part of the patientscontin- uing care at the University of Michigan, we did not find them to be effective in diagnosing the small occlusal carious lesions of interest in this study. This was most likely due to the limited size of the lesions and their varied location on the occlusal surface. At each recall examination, all study teeth were evaluated independently by two dentists for gingival health. The quality of the restorations was evaluated according to modified Ryge criteria, 16 and the retention of sealants was assessed according to the following criteria: pres- ent, partially lost and completely lost (Box 2). The dentists evaluated control teeth for color of the pit and fissure system, explorer retention and caries using the same criteria as those used at baseline: softness at the base of a pit or fissure, decalcification associated with a pit or fissure, or radiographic signs of caries. If a control tooth was diagnosed as having caries, it was treated exactly the same as a tooth that had been randomized to the treatment group at baseline. All teeth were

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RESEARCH

BOX 2

MODIFIED RYGE EVALUATION CRITERIA FOR THE EARLY TREATMENT GROUP AND TREATED CONTROL TEETH.*

 

COLOR MATCH

 

O

A

Visually undetectable Visually detectable no mismatch in color

B

Mismatch in color within acceptable range

C

Mismatch in color outside acceptable range

 
 

MARGINAL DISCOLORATION

 

A

No discoloration anywhere on the margin

B1

Discoloration noted along margin less than 50 percent of exposed margin

B2 Discoloration noted along margin greater than 50 percent of exposed margin

C

Discoloration penetrating along margin

 

MARGINAL ADAPTATION

 

A1

Restorative material is continuous with adjacent tooth structure

A2 Restorative material presents a one-way catch to an explorer

B

Visible evidence of crevice formation that an explorer will penetrate

C

Visible evidence of crevice formation with exposure of dentin or base

 

ANATOMICAL FORM

 

A

Restoration contour is continuous with existing anatomical tooth form

B

Restoration is undercontoured with respect to existing anatomical tooth form

C

Restoration is undercontoured with dentin or base exposed

 
 

SURFACE SMOOTHNESS

A

Smooth as natural adjacent tooth structure

B

Surface not as smooth as natural tooth structure but not pitted

C

Surface not as smooth as natural tooth structure and pitted

 

SEALANT PRESENT

 

A

B

All pits and fissures are covered Partial loss of sealant with some pits and fissures exposed

C

All pit and fissure sealant lost

 
 

*

Source: Ryge and Snyder. 16 O: Oscar; A: Alfa; B: Bravo; C: Charlie.

photographed at each recall examination. The dental assistant or research coordinator recorded the independent scores for each criteria from the two dentists; if there was any disagree- ment, the dentists reviewed the written criteria and reached a consensus. The evaluators agreed 84 percent of the time before any review or dis- cussion took place. (Agreement ranged from 65 percent for evaluation of pit and fissure feel to 91 percent for evaluation of anatomical form and presence of sealant.) All dentist authors, in pairs of two, were evaluators. Drs. Hamilton and Den- nison prepared and placed all restorations, but did not necessarily evaluate all restorations or preparations at recall appointments. Dentist eval- uators used ×2.5 magnification and an explorer to evaluate caries into dentin and the elimination of carious tooth structure. Table 1 shows the distribution of the 223 con- trol and treated teeth among the 93 patients. The distribution of molars and premolars between the

control and treatment

groups is shown in Table 2.

Statistical analy-

sis. At yearly inter- vals, we used the χ 2 test to compare the number of teeth with carious lesions extending into dentin in the early treatment group with the number that were diagnosed and treated in the control group. We also used discrete time survival analysis with logistic regres- sion, 17 as implemented in SAS software release 8.2 (SAS Insti- tute, Cary, N.C.), to determine the per- centage of control teeth becoming carious. Logistic regression

with generalized esti- mating equations for clustered data was used to determine which baseline factors (that is, pit and fissure color, pit and fissure feel, baseline DMFS index, fluoride use history, age, sex and tooth type) were related to control teeth that were subsequently diagnosed as having

occlusal caries, as well as to treated teeth that had caries extending into dentin. The weights of the preparation impressionsa surrogate mea- sure of volumeof the early treated teeth and the control teeth subsequently diagnosed as having caries and treated were compared using a t test for independent samples. A P value of less than .05 was considered significant.

RESULTS

The dentists re-examined 89 control teeth at 24 months or longer (because patients were treated at staggered times). Nine (10 percent) of the teeth were diagnosed and treated for caries after one year; five additional teeth (6 percent) were diag- nosed and treated in the second year. We found no significant effect of time on caries occurrence

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RESEARCH

in the control group (P = .8470). This means that the probability of a questionable carious lesion in the control group being diagnosed with caries did not increase or decrease significantly during the two years. The probability of caries developing in teeth in the control group after two years was 16.1 percent (95 percent confi- dence interval, 9.3 percent

TABLE 1

DISTRIBUTION OF TEETH TREATED AT BASELINE AND CONTROL TEETH. VARIABLE NUMBER OF TEETH TOTAL All Control
DISTRIBUTION OF TEETH TREATED AT BASELINE AND
CONTROL TEETH.
VARIABLE
NUMBER OF TEETH
TOTAL
All Control
Two
One
One
All
Teeth
Control
Control
Control
Treatment
Teeth and
Tooth and
Tooth and
Teeth
One
One
Two
Treatment
Treatment
Treatment
Tooth
Tooth
Teeth
No. of
23
20
7
20
23
93
Patients
No. of
43
60
14
60
46
223
Teeth

TABLE 2

DISTRIBUTION OF TOOTH TYPE BETWEEN TREATMENT AND CONTROL GROUPS. TOOTH TYPE NUMBER OF TEETH Treatment Group
DISTRIBUTION OF TOOTH TYPE
BETWEEN TREATMENT AND
CONTROL GROUPS.
TOOTH TYPE
NUMBER OF TEETH
Treatment Group
Control Group
Third Molar
1
3
Second Molar
54
48
First Molar
41
41
Second
7
11
Premolar
First Premolar
10
7
TOTAL
113
110

appropriate treatment for many of the question- able carious lesions in this study, we did not use them because the hypothesis being investigated was the advantage of early operative intervention into questionable carious lesions in the pits and fissures of posterior teeth. At baseline, we discovered that caries had pro- gressed into dentin in 50 (44 percent) of the 113 teeth with questionable carious lesions random- ized into the early treatment group. After two years, only 14 teeth randomized into the control group were diagnosed with caries. The criteria we used for diagnosing caries throughout the study was softness at the base of a pit or fissure, decal- cification associated with a pit or fissure, or cavitation. Probed teeth. We probed control teeth exten- sively with an explorer. This leads to two con- cerns: the possible transmission of cariogenic bac-

to 26.3 percent). The number of control teeth diagnosed with caries during the first two years of the study was significantly less than the number of teeth with caries that extended into dentin in the treatment group at baseline (P < .001). The mean weight of the impression material in preparations that extended into dentin (a surro- gate measure of tooth structure volume) in the early treatment group was 0.0260 grams, com- pared with 0.0281 g in the control group. This was not a statistically significant difference (P = .390). The only significant baseline predictor of a control tooth being diagnosed with caries was pit and fissure feel evaluated with an explorer (P = .0149). This means that the more retentive the explorer was in the pit or fissure, the more likely the control tooth would be diagnosed as having caries and treated during the next 24 months. Table 3 shows the results of clinical evalua- tions of preventive resin restorations and sealants placed at baseline using modified Ryge criteria 16 at six months, 12 months, 18 months and 24 months. During the second year of the study, no restorations required re-treatment compared with two restorations needing re-treatment during the first year of the study. Table 4 (page 1649) shows the results of the evaluations of gingival health and the plaque index for all teeth and pit and fis- sure color and pit and fissure feel of control teeth at six months, 12 months, 18 months and 24 months. Figure 1 (page 1650) shows the 24-month appearance of a tooth in the early treatment group. Figure 2 (page 1650) shows the 24-month appearance of a tooth in the control group.

DISCUSSION

Although pit and fissure sealants would be an

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RESEARCH

TABLE 3

obtain an estimate of the percentage of control teeth with questionable carious lesions that would progress to unquestion- able caries each year of

the study. Although no previous study examined only questionable carious

lesions, the cariologists

estimate was that 25 per- cent of the teeth would become carious each year.

Since 44 percent of the

teeth randomized to the

early treatment group

had clinically demon-

strated caries that had progressed into dentin when treated at baseline,

we expected to find more

than 25 percent of the

control teeth exhibiting caries during each of the

first two years. One possible explana-

tion for the low number of

control teeth exhibiting

caries each year is that the rate of progression of

caries in this population

is lower than expected.

Other possible explana-

tions are that the caries had arrested or reminer- alization had occurred,

although these possibili-

ties run counter to cur-

rent thinking about pro- gression of pit and fissure

CLINICAL EVALUATION RESULTS OF TEETH TREATED AT BASELINE.* CATEGORY † NO. (PERCENTAGE) OF TEETH Six Months
CLINICAL EVALUATION RESULTS OF TEETH TREATED AT
BASELINE.*
CATEGORY †
NO. (PERCENTAGE) OF TEETH
Six Months
12 Months
18
Months
24 Months
Color Match
Oscar
58
(98)
50
(89)
40
(91)
43
(86)
Alfa
1
(2)
6 (11)
4
(9)
7
(14)
Marginal Discoloration
Alfa
59
(100)
54
(98)
42
(95)
49
(98)
Bravo 1
0
0
2
(5)
0
Bravo 2
0
0
0
1
(2)
Charlie
0
2
(2)
0
0
Marginal Adaptation
Alfa 1
55
(93)
51
(91)
36
(82)
39
(78)
Alfa 2
4
(7)
2
(4)
6
(14)
9
(18)
Bravo
0
3
(5)
2
(4)
2
(4)
Charlie
0
0
0
0
Anatomical Form
Alfa
59
(100)
55
(98)
43
(98)
46
(92)
Bravo
0
1
(2)
1
(2)
4
(8)
Surface Smoothness
Alfa
58
(98)
54
(96)
38
(86)
46
(92)
Bravo
1
(2)
1
(2)
5
(11)
4
(8)
Charlie
0
1
(2)
1
(2)
0
Sealant Present
Alfa
57
(97)
55
(98)
41
(93)
48
(96)
Bravo
1
(2)
0
0
1
(2)
Charlie
1
(2)
1
(2)
3
(7)
1
(2)
* Because it was not possible to distinguish preventive resin restorations from prepared sealants, they are
combined in the table.
† Based on criteria from Ryge and Snyder. 16

teria from one tooth to the next, and damage to decalcified enamel and increased demineraliza- tion. 18,19 If these events took place, we would expect that a greater number of control teeth would be diagnosed and treated for caries than would otherwise be the case. However, this did not happen during the 24 months of this study. Cariologists’ estimate. Before the study began, we consulted with two cariologists to

caries that has extended into dentin. Current explanations may have to be reconsidered if the caries rate in the control group remains low. DMFS scores. Another possible explanation for a lower-than-expected caries rate might be related to the caries experience or susceptibility of the enrolled subjects. One measure of dental caries experience or prevalence is the number of DMFS present. The DMFS score for enrolled patients ranged from 0 to 58, with a mean of 8.42 and a standard deviation of 7.47. Figure 3 (page

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RESEARCH

1650) illustrates the dis- tribution of DMFS scores and their association with study teeth. It is inter- esting to note that four teeth in the study were in patients with a DMFS score of 0, while one patient (one tooth) had a DMFS score of 58. Thus the caries prevalence varied within the study. The mean DMFS scores of the group treated at baseline and the control group were 9.26 and 7.43, respec- tively. This difference is not statistically signifi- cant (P = .087). However, because the P value is approaching a commonly accepted level of signifi- cance (P < .05), this issue deserves further investigation. As noted in the 12- month results, 20 demo- graphic and baseline evaluation variables asso- ciated with teeth in the early treatment group were analyzed using logistic regressions with generalizing equations. DMFS was not signifi- cantly related to caries

TABLE 4

CLINICAL EVALUATION RESULTS AT RECALL APPOINTMENTS. CATEGORY NO. (PERCENTAGE) OF TEETH Six Months 12 Months 18
CLINICAL EVALUATION RESULTS AT RECALL
APPOINTMENTS.
CATEGORY
NO. (PERCENTAGE) OF TEETH
Six Months
12 Months
18 Months
24 Months
Gingival Health*
(All Study Teeth)
Normal
112 (93)
98
(91)
76
(92)
90
(93)
Marginal Gingivitis
8
(7)
10
(9)
7
(8)
7
(7)
Plaque Index †
(All Study Teeth)
0
65
(54)
60
(56)
40
(48)
53
(55)
1
40
(33)
33
(31)
36
(43)
40
(41)
2
14
(12)
12
(11)
7
(8)
4
(4)
3
1
(1)
3
(3)
0
0
Pit and Fissure Color
(Control Teeth)
Tooth Color
3
(5)
0
0
0
Yellow/Orange
3
(5)
3
(6)
0
2
(4)
Light Brown
18
(29)
17
(33)
16
(41)
18
(38)
Dark Brown
38
(60)
31
(60)
22
(56)
27
(57)
Black
1
(2)
1
(2)
1
(3)
0
Pit and Fissure Feel
(Control Teeth)
No Stick
38
(62)
22
(42)
21
(54)
21
(45)
Slight Stick
15
(25)
20
(39)
13
(33)
17
(36)
Resistance to
8
(13)
10
(19)
5 (13)
9 (19)
Removal
* Source: Löe and Silness. 12
† 0: No plaque visible; 1: film of plaque visible only with periodontal probe; 2: moderate amount of soft
deposits visible; 3: abundant amount of soft deposits visible. Source: Greene and Vermillion. 13

fact is, however, that despite the lower mean DMFS score in the control group and our use of aggressive probing, the caries rate was still lower than expected in the control group. When comparing the size of the preparations in the early treatment and control groups, we found it surprising how small these preparations were and how small the difference was between the two groups. (The mean weights of the impressions from the two groups differed by only 0.0021 g, or 1.6 cubic millimeters in size.) Darkly stained pits and fissures often have been associated with caries. In this study, these pits and fissures were divided into five categories

extending into dentin in the early treatment group, but was borderline (P = .056). The sur-

prising fact is that the higher the DMFS score was at baseline, the less likely that caries had extended into dentin in teeth randomized into the treatment group. One possible explanation is that the most susceptible surfaces had already been restored, leaving only those surfaces that were more resistant to caries. In addition, this could be construed as the lower ones DMFS score, the more likely that caries had extended into dentin and that the con- trol group, which had a lower overall DMFS, would have more caries into dentin than the early treatment group, which had a higher DMFS. The

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NUMBER OF STUDY TEETH

RESEARCH

NUMBER OF STUDY TEETH RESEARCH Figure 1. Preventive resin restoration in the mandibular first molar at

Figure 1. Preventive resin restoration in the mandibular first molar at 24-month recall examination.

NUMBER OF STUDY TEETH RESEARCH Figure 1. Preventive resin restoration in the mandibular first molar at

Figure 2. Control tooth (mandibular second molar) at 24- month recall examination.

ranging from tooth colored (nearly white) to black. This color range can be considered a con- tinuous scale, and it was clear to the evaluators that in certain cases, there would be difficulty dis- tinguishing a difference in adjacent categories, such as between tooth color and light yellow, between light brown and dark brown, and

30

20

10

0

NUMBER OF STUDY TEETH RESEARCH Figure 1. Preventive resin restoration in the mandibular first molar at

0

1

2

3

4

5

6

7

8

9 10 11 12 13 14 15 16 21 22 24 27 58

DMFS SCORES

Figure 3. Caries prevalence as indicated by decayed, missing and filled surfaces, or DMFS, scores of patients associated with study teeth.

between dark brown and black. Consequently, the level of agreement (84 percent) between the eval- uators was not unexpected. When we reduced the color scale to two categories (no stain [tooth color and yellow/orange] and stained [light brown, dark brown and black]), the agreement between evalu- ators was an acceptable 88 percent. Use of dental explorer. Using a dental explorer to probe the pits and fissures of teeth has often been an aid in diagnosing carious lesions 21 ; however, many cariologists do not recommend the use of aggressive probing. 18,19 Although specific explorers were purchased and used in this clinical study, we found differences between similar explorers. We also noted that the explorers were used with different pressures by different exam- iners. In retrospect, we should have developed pressure criteria. Moreover, it was clear to all examiners that physical changes to the pits and fissures occurred as a result of probing that made calibration impossible. In many cases, the pit or fissure became less retentive the more the tooth was probed. Given these problems, it is interesting to note that we found a strong relationship between pit and fissure feel and caries penetrating into dentin (P = .0149). The greater the retention of the explorer at the baseline examination, the more likely the control tooth would be diagnosed and treated for caries during the next 24 months. Although patients were excluded from the study if they had five or more active carious lesions, only one patient had an extensively cavi- tated lesion on enrollment. In retrospect, this

  • 1650 JADA, Vol. 133, December 2002

Copyright ©2002 American Dental Association. All rights reserved.

RESEARCH

RESEARCH Dr. Hamilton is a clinical associate pro- fessor, Department of Cariology, Restorative Sciences and Endodon-
RESEARCH Dr. Hamilton is a clinical associate pro- fessor, Department of Cariology, Restorative Sciences and Endodon-
RESEARCH Dr. Hamilton is a clinical associate pro- fessor, Department of Cariology, Restorative Sciences and Endodon-

Dr. Hamilton is a clinical associate pro- fessor, Department of Cariology, Restorative Sciences and Endodon- tics, the University of Michigan School of Dentistry, 1011 N. University, Ann Arbor, Mich. 48109-1078, e-mail jchamilt@ umich.edu. Address reprint requests to Dr. Hamilton.

Dr. Dennison is a pro- fessor, Department of Cariology, Restorative Sciences and Endo- dontics, the University of Michigan School of Dentistry, Ann Arbor.

Dr. Stoffers is an assist- ant professor, Depart- ment of Cariology, Restorative Sciences and Endodontics, the University of Michigan School of Dentistry, Ann Arbor.

might have been expected, because if a patient has many

grossly carious teeth, it could indicate a high caries rate. We would expect that teeth with questionable carious lesions would not stay questionable for long in a patient with a high caries rate. Caries-detecting dyes. Before this study began, we decided not to use any caries-detecting dye to aid in locating or removing carious dentin. This decision was based on two factors:

dA review of the published literature indicated diverse opinions regarding the effectiveness of caries-detecting dyes. dWe wanted to use procedures that were com- monly practiced by general dentists. In a review article on the efficacy of caries- detecting dyes, McComb 22 noted that with proper dental care, they were not necessary. None of the patients requested local anesthetic during treatment of the five control teeth in the second year of the study, compared with one patient in the first year. No patient reported any preoperative or postoperative sensitivity asso- ciated with any study tooth. Both of these find- ings suggest that the questionable carious lesions in the control group are not progressing quickly. This study did not measure the amount of tooth structure lost as a result of early treatment of the 63 teeth in which the questionable carious lesions were limited to enamel. We also did not

predict the costs related to the lifetime mainte- nance these prepared sealants require. The lost tooth structure and lifetime maintenance costs need to be weighed against the benefits of treating caries at an early stage.

CONCLUSION

The results of this study show that after two

RESEARCH Dr. Hamilton is a clinical associate pro- fessor, Department of Cariology, Restorative Sciences and Endodon-

Dr. Gregory is an adjunct professor of dentistry, Department of Cariology, Restora- tive Sciences and Endodontics, the Uni- versity of Michigan School of Dentistry, Ann Arbor.

years, tooth structure was not conserved as a result of early treatment of questionable carious lesions in posterior teeth. The degree of explorer retention at baseline was significantly asso- ciated with caries being diag- nosed later in control teeth. The preventive resin restorations and sealants placed in the early treat- ment group were performing well after two years.

Ms. Welch is a statistical consultant, Center for Statistical Consultation and Research, The University of Michigan, Ann Arbor.

This investigation was partially supported by Delta Dental Fund of Michigan.

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