abstract phd thesis - umf iasi content genreral part introduction.....4

FACULTY OF DENTAL MEDICINE

STUDIES ON THE ROLE OF THE ADDITIONAL TESTS IN THERAPEUTICAL MANAGEMENT OF INCIPIENT

DENTAL CARIES

Scientific coordinator

PROF.UNIV.DR. ANDRIAN SORIN

PhD Student

TOPOLICEANU CLAUDIU

2014

ABSTRACT

PhD THESIS

I

CONTENT

GENRERAL PART

INTRODUCTION....................................................................................................................4

CHAPT. I.ACTUAL DATA REGARDING CARIOUS DISEASE.....................................5

I.1. PHYSICAL, CHEMICAL, MORPHOLOGICAL ASPECTS......................................5I.2. ETIOPATHOGENICAL ASPECTS..............................................................................10I.3.CLASSIFICATION SYSTEMS OF OCCLUSAL DENTAL CARIES...................................................................................................................................14I.4.EPIDEMIOLOGICAL DATA REGARDING OCCLUSAL DENTAL CARIES...................................................................................................................................16

CHAPT.II. DETECTION AND DIAGNOSTIC OF OCCLUSAL CARIOUS LESIONS USING CLINICAL EXAMEN..............................................................................................18

CHAPT.III. DETECTION AND DIAGNOSTIC OF OCCLUSAL CARIOUS LESIONS USING PARACLINICAL TECHNIQUES..........................................................................23

III.1.CONVENTIONAL AND DIGITAL RADIOGRAPHIC EXAMEN........................23III.2.LASERFLUORESCENCE METHOD....................................................................... 29

CHAPT.IV. THERAPEUTICAL MANAGEMENT OF INCIPIENT OCCLUSAL DENTAL CARIES.................................................................................................................41

PERSONAL PART

CHAPT.V. MOTIVATION OF THEME CHOICE. OBJECTIVES. METHODOLOGY.................................................................................................................46

CHAPT.VI. STUDY REGARDING PREVALENCE AND DISTRIBUTION OF INCIPIENT OCCLUSAL DENTAL CARIES ...............................................................49 Introduction..................................................................................... ...................................49Aim of study............................................................................................................................50Materials and method............................................................................................................51Results......................................................................................................................................52Discussions..............................................................................................................................64Conclusions.............................................................................................................................70

II

CHAPT.VII. CHEMICAL CHANGES IN DENTAL SURFACES AFFECTED BY DENTAL CARIES: EDX STUDY .......................................................................................71 Introduction................................................................................................................. .......71 Aim of study............................................................................................................................71 Materials and method............................................................................................................71Results......................................................................................................................................76 Discussions..............................................................................................................................94 Conclusions.............................................................................................................................96

CHAPT.VIII. STUDY REGARDING ROLE OF BYTE-WING METHOD IN MANAGEMENT OF INCIPIENT OCCLUSAL DENTAL CARIES .........................97Introduction................................................................................................................. .......97 Aim of study............................................................................................................................97 Materials and method............................................................................................................97Results....................................................................................................................................98 Discussions............................................................................................................................108 Conclusions...........................................................................................................................111

CHAPT.IX. STUDY REGARDING ROLE OF LASERFLUORESCENCE METHOD IN MANAGEMENT OF INCIPIENT OCCLUSAL DENTAL CARIES..................112 Introduction................................................................................................................. .....112 Aim of study..........................................................................................................................112 Materials and method..........................................................................................................112Results....................................................................................................................................114 Discussions............................................................................................................................134 Conclusions...........................................................................................................................137

CHAPT.X. STUDY REGARDING CURRENT APPROACHES IN DIAGNOSTIC AND THERAPEUTICAL MANAGEMENT OF OCCLUSAL CARIES..................112 Introduction................................................................................................................. .....112 Aim of study..........................................................................................................................112 Materials and method..........................................................................................................112Results....................................................................................................................................114 Discussions............................................................................................................................134 Conclusions...........................................................................................................................137

GENERAL CONCLUSIONS..............................................................................................164

ORIGINALITY....................................................................................................................166

REFERENCES.....................................................................................................................167

3

Key words: incipient occlusal caries, prevalence, byte-wing radiography, Diagnodent, therapeutical management PhD Thesis contains:

general part organized in 4 chapters (45 pag.); personal researches organized 5 chapters (115 pag.); 117 tables and 144 figures; 192 references.

Note: the abstract presents selective references and images in text, respecting numbering and content of PhD Thesis

4

CHAPT.VI. STUDY REGARDING PREVALENCE AND DISTRIBUTION OF INCIPIENT OCCLUSAL DENTAL CARIES

AIM OF STUDY. The aim of study was to determine, using ICDAS system and laserfluorescence, the prevalence and distribution of incipient occlusal dental caries, in relation to some patients factors. MATERIALS AND METHOD Study group included 115 patients with age between 18-30 years. 1960 occlusal surfaces were assessed using visual method (ICDAS system) and laserfluorescence method (DIAGNODENT, Kavo). The occlusal surfaces with ICDAS codes 01-02 and Diagnodent values under 10 were considered healthy. The prevalence was repported to total number of investigated occlusal surfaces, and distribution was assessed in relation to sex (males, females, age (18-23 years, 24-30 years), dental group (molars, bicusps, anterior teeth, maxillary teeth, mandibular teeth), cariogenic risk (low, medium, high). Statistical analysis (Mann-Whitney, Wilcoxon tests) was performed using SPSS17. The results were expressed using tables and graphs performed in Excel. RESULTS

Figures1.a-b., 2.a-b., 3.a-b., 4.a-b. present clinical aspects and Diagnodent recording of occlusal surfaces affected by incipient carious lesions.

Fig.1.a. Incipient occlusal caries (3.7.). ICDAS 02

Fig.1.b. Diagnodent 17 (enamel caries)

1

5

Fig.2.a.Incipient occlusal dental caries (4.6.). ICDAS 03.

Fig.2.b. Diagnodent 22.

Fig.5. Prevalence of incipient occlusal dental caries

Fig.6. ICDAS codes in study group

68,80%

31,20% Suprafete

ocluzaleintegre

Suprafeteocluzale cucarii incipiente

4,50%

44%40,10%

11,40%

ICDAS 01

ICDAS 02

ICDAS 03

ICDAS 04

2

6

Fig.7. Diagnodent values in study group

Fig 11.a.Prevalence of incipient occlusal dental caries (males)

Fig.11.b. Prevalence of incipient occlusal dental caries (females)

Fig.12.a.Prevalence of incipient occlusal dental caries (age group 18-23 years)

Fig.12.b. Prevalence of incipient occlusal dental caries (age group 24-30 years)

60%17,50%22,50% 10-20.

20-30

>30

29,87%

70,13%

Carii incipiente

Suprafeteocluzaleintegre

Sex masculin

30,86%

69,14%

Cariiincipiente


Sex feminin

29,90%

70,10%

Carii incipiente


18-23 ani

19,40%

80,60%

Carii incipiente


24-30 ani

3

7

Fig.13. Prevalence of incipient occlusal dental caries related to cariogenic risk CONCLUSIONS

Prevalence of incipient occlusal dental caries is 31.30% (repported to total number of occlusal surfaces).

Prevalence of incipient occlusal dental caries is related to cariogenic risk category: 18,75% for low cariogenic risk, 32,10% for medium cariogenic risk, 37,1% for high cariogenic risk.

The distribution of ICDAS codes is influenced by cariogenic risk category, with significant statistical differences between low cariogenic risk and medium cariogenic risk, low cariogenic risk and high cariogenic risk.

ICDAS 02 and 03 are associated especially with low cariogenic risk and medium cariogenic risk, ICDAS 04 is mostly associated with high cariogenic risk.

Maxillary molars are most affected by incipient occlusal dental caries, followed by mandibular molars, maxillary bicusps and mandibular bicusps.

0,00%10,00%20,00%30,00%40,00%

Risccariogen

mic

Risccariogen

mediu

Risccariogen

mare

18,75%31.10% 37,10%

4

8

CHAPT.VII. CHEMICAL CHANGES IN DENTAL SURFACES AFFECTED BY DENTAL CARIES: EDX STUDY AIM OF STUDY

Aim of study was to determine loss of Ca and P ions on white-spot and brown-spot enamel areas and to compare these areas with healthy enamel, as well as to determine minerals loss in different areas of the same enamel carious lesion. MATERIALS AND METHOD

Study group consisted of 20 third molars extracted for orthodontic reasons. Teeth were randomly divided in three groups: A (control)- 20 healthy enamel surfaces; B- 10 white-spot enamel surfaces; C- 10 brown-spot enamel surfaces. The confirmation of diagnostic was performed using laserfluorescence method. Figures 16.-17.a-b present aspects of occlusal surfaces and Diagnodent recordings.

Fig. 16.a.White-spot (4.8.)

Fig. 16.b. Diagnodent 17

Fig. 17.a.Brown-spot (3.8.)

Fig. 17.b. Diagnodent 21

5

9

vestibulo-4

-rays

Examinarea SEM/EDX a fost realizat pentru fiecare dinte pe demineralizat.

A fost utilizat testul statistic t independent

RESULTS

EDX method detected Ca and P ions as major chemical elements (qualitative analysis). Thus all quantitative analysis were performed for Ca and P.

Fig.20. Spectru EDX al el Table 5. Quantitative analysis for healthy enamel. Element series [wt.-%] [norm.

wt.-%] [norm. at.-%]

Error in %

Calcium K-series

51.38323 51.38375 34.84899 1.576058

Phosphorus K-series

20.56203 20.56224 18.04459 0.887405

Oxygen K-series

28.05373 28.05401 0.471064 3.869274

Sum: 99.999 100 100

6

10

Fig.21. White-spot. EDX spectrum of chemical elements. Tabel 6. White-spot. Quantitative analysis.

Element series [wt.-%] [norm. wt.-%]

[norm. at.-%]

Error in %

Calcium K-series 29.2335 29.09668 15.25653 0.885081 Phosphorus K-series 18.22746 18.17023 8.257021 0.51954 Oxygen K-series 62.54903 62.73409 63.2845 3.43998 Sum: 99.999 100 100

Fig.22. Brown-spot. EDX spectrum of chemical elements. Tabel 7. Brown spot. Quantitative analysis.

Element series [wt.-%] [norm. wt.-%]

[norm. at.-%]

Error in %

Calcium K-series 35.16424 35.16464 23.12364 1.191806 Phosphorus K-series 17.991 17.99118 13.59186 0.756533 Oxygen K-series 46.84375 46.84418 63.2845 3.43998 Sum: 99.999 100 100

7

11

Fig.23. White-spot. Variations of Ca and P for different enamel areas.

Fig.24. Brown-spot. Variations of Ca and P levels related to different enamel areas. Table 8.b. Mean values of Ca and P for healthy enamel, white-spot (WS), brown-spot (BS).

Table 8.c. Mean values of Ca and P for (DMZ-MIN) and (DMZ-MAX) on enamel surfaces with white-spot (WS), and brown-spot (BS). Lot DMZ-MIN DMZ-MAX Ca P Ca P White-spot (WS)

42.83 21.50 16.93 8.71

Brown-spot (BS)

45.72 23.76 31.99 16.49

Lot Mean values Ca, P (wt%) Ca P

Control (DM0) 53.40 23.74 White-spot (WS) 29.85 15.12 Brown-spot (BS) 38.82 20.11

8

12

CONCLUSIONS

Enamel surfaces affected by incipient carious lesions are associated with high loss of Ca, P ions; significant statistical differences were demonstrated between demineralised enamel areas and healthy enamel.

Significant statistical differences between white-spot and brown-spot carious lesions are recorded regarding Ca, P levels, with higher levels in brown-spot areas.

Each white-spot and brown-spot lesion presents minimal demineralisation area and maximal demineralisation area, with significant statistical differences regarding Ca, P content.

The areas with minimal demineralisation from white-spot and brown-spot carious lesions do not present significant statistical differences regarding Ca, P levels.

9

13

CHAPT.VIII. STUDY REGARDING ROLE OF BYTE-WING RADIOGRAPHY METHOD IN THERAPEUTICAL MANAGEMENT OF INCIPIENT OCCLUSAL DENTAL CARIES AIM OF STUDY

The aim of study was to determine accuracy of byte-wing radiography in detection of incipient occlusal carious lesions extended in dentine.

MATERIALS AND METHOD

Study was performed on 30 patients (18-60 years) with high cariogenic risk, including 33 molars with clinically diagnosed incipient occlusal surfaces (ICDAS codes 02-04). Written consent was obtained from all patients included in study group.

All occlusal surfaces were examined clinically (ICDAS codes) and radiographically by a single experienced examinator trained and calibrated. The validation was performed using minimal operative intervention (RPP) with 330 bur.

The used radiographic indices were as follows:

E0- no radiotranslucency; E- radiotranslucency limited to enamel; D1- radiotranslucency extended in dentine external third; D2- radiotranslucency extended in medium external third. The sensitivity, specificity, accuracy of byte-wing radiographic examen were

calculated . The accuracy values of byte-wing radiography were compared with visual method (ICDAS) using test McNemar.

The accuracy of therapeutical decisions was compared between byte-wing and visual method (ICDAS) and between byte-wing and when byte-wing was used as additional test to visual method (ICDAS).

. The results were expressed as tables and graphs performed in Excel. RESULTS

In figures 27.a-b., 28.a-b., 29.a-b. are presentes clinical aspects and radiographic aspects regarding investigated incipient occlusal carious lesions.

Fig.27.a. H.C. ICDAS 03 (2.6.).

10

14

Fig.27.b. H.C. D1 (3.6.).

Fig.28.a. M.A.ICDAS 02 (4.7.). \

Fig.28.b.M.A. E0 (4.7.).

Fig.29.a. I.O. ICDAS 02 (3.6.).

Fig.29.b. I.O. D1 (3.6.).

In figures 30.a.-30.d. are presented data regarding study group:ICDAS, radiographic indices, demineralised tissues, demineralisation depth.

Fig.30.a. Distribution of Rx indices in study group

36,30%

27%

27,70%

9%

E0

E

D1

D2

11

15

Fig.30.b. Distribution of ICDAS in study group

Fig.30.c. Distribution of carious lesions related to demineralized tissues

Fig.30.d. Distribution of carious lesions related to demineralisation depth

Fig.31. Distribution of Rx indices related to ICDAS

51,50%42,40%

6,10%

ICDAS 02

ICDAS 03

ICDAS 04

27,25%

72,75%Smalt

Dentina

27%

67%

6%

E

D3

D4

0%20%40%60%80%

100%

E0 E D1 D2 E0 E D1 D2 E0 E D1 D2

ICDAS 02 ICDAS 03 ICDAS 04

53%

29,50%17,50%

0%

21,50%28,50%

50%

0% 0% 0% 0%

100%

12

16

Fig.32. Distribution of ICDAS related to Rx indices

Fig.33. Distribution of Rx indices related to demineralized tissue

Fig.34. Distribution related to demineralized tissue and Rx indices

Fig.35. Distribution of Rx indices related to demineralisation depth

0%20%40%60%80%

100%

E0 E D1 D2

75%

25%

0% 0%

66%

33%

0% 0%

50%50%

0% 0% 0% 0% 0%

100%

0%10%20%30%40%50%60%70%

E0 E D1 D2 E0 E D1 D2

SMALT DENTINA

66%

22%11%

0%

24%30%

37%

9%

0%

20%40%60%80%

100%

E0 E D1 D2

50% 50%33%

66%

17,50%

82,50%

0%

100%

80%

20%

0% 0%

50%

0%

25% 25%

0%

45% 55%

0% 0% 0% 0%

100%

0%

20%

40%

60%

80%

100%

120%

E0 E D1 D2 E0 E D1 D2 E0 E D1 D2 E0 E D1 D2

D1 D2 D3 D4

13

17

The results regarding diagnostic performance of byte-wing radiography are presented in figure 36 (sensitivity, specificity, accuracy)

Fig.36. Radiography BW. Sensitivity (SE), specificity (SP), accuracy (AC) for cut-off D3 (dentinal caries). Table 54.b. Test McNemar between byte-wing and visual method (ICDAS)

Test Statisticsb

RXaccuracy &

ICDASaccuracy

N 33

Exact Sig. (2-tailed) 1.000a

a. Binomial distribution used.

b. McNemar Test The results of McNemar test (table 54.b) indicate the absence of significant statistical differences between byte-wing and visual method (ICDAS) in detection of incipient occlusal dental caries (significance level 1.000) Table 55.a-b. Accuracy of therapeutical decisions related to diagnosis method.

Non-intervention RPP

Enamel caries Dentinal caries Enamel caries Dentinal caries

(D1-D2) (D3-D4) (D1-D2) (D3-D4)

RX 9 12 1 11

ICDAS 6 12 3 12

ICDAS+RX 6 10 4 13

0

0,2

0,4

0,6

0,8

1

SE SP AC

0,44

0.90

0,57

14

18

Non-intervention RPP

Enamel caries Dentinal caries Enamel caries Dentinal caries

(D1-D2) (D3-D4) (D1-D2) (D3-D4)

RX 43% 57% 9% 91%

ICDAS 38% 62% 25% 75%

ICDAS+RX 40% 60% 27% 73%

Fig.37.Accuracy of non-intervention decisions related to diagnosis method

Fig.38.Accuracy of RPP decisions related to diagnostic method

0%

20%

40%

60%

80%

100%

120%

RX ICDAS ICDAS+RX

43% 38% 40%

57% 62% 60% Monitorizare/preventieCarii dentinare (D3-D4)

Monitorizare/preventieCarii de smalt (D1-D2)

0%

20%

40%

60%

80%

100%

120%

RX ICDAS ICDAS+RX

9% 25% 27%

91% 75% 73%Tratament restaurativCarii dentinare (D3-D4)

Tratament restaurativCarii de smalt (D1-D2)

15

19

CONCLUSIONS

Byte-wing radiography detects 27% enamel radiotranslucencies and 26.75% dentinal radiotranslucencies (D1-D2).

Enamel rradiotranslucency is associated in 66% percentages with dentine demineralisation; radiotranslucency in dentine external third is associated in 90% percentages with dentine demineralisation; radiotranslucency in dentine medium third is associated in 100% percentages with dentine demineralisation.

Byte-wing examen used in diagnosis of incipient occlusal dental caries, has 0.44 sensitivity, 0.90 specificity and 0.57 accuracy.

No significant statistical differences were demonstrated between radiographic examen and visual examen regarding detection of incipient occlusal caries.

16

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CHAPT.IX. STUDY REGARDING ROLE OF LASERFLUORESCENCE METHOD IN THERAPEUTICAL MANAGEMENT OF INCIPIENT OCCLUSAL DENTAL CARIES THE AIMS OF STUDY

1. to determine in vivo and in vitro sensitivity, specificity, accuracy of laserfluorescence method in detection of incipient occlusal dental caries;

2. to determine optimal cut-off for detection of occlusal enamel and dentine caries;

3. to establish possible correlation between Diagnodent values and depth of occlusal carious lesions.

4. To determine accuracy of therapeutical decisions regarding incipient occlusal dental caries when visual method is combined with laserfluorescence method.

MATERIALS AND METHOD

The in vivo study was performed on 78 molars and bicusps with questionable occlusal areas, in a study group of 65 patients with high cariogenic risk (age between18-30 years).From all patients written consent was obtained. The in vitro study was performed on 25 third molars extracted from orthodontic reasons with 50 investigated occlusal sites 3

-au dat acordul scris de participare la acest studiu.

All occlusal surfaces were assessed using visual method (ICDAS codes) and laserfluorescence method (Diagnodent, KaVo) by a single experienced examinator trained and calibrated. The validation for in vivo study was performed after minimal operative intervention with 330 bur and measurement with periodontal probe.The validation for in vitro study was performed by histological examen, after sectioning teeth with diamond discs under water cooling. The samples were examined with optic microscope (Neophot 21, x20).

Occlusal carious lesions were classified accordingly to Downer indice (enamel caries D1-D2, dentinal caries D3-D4). The histological assessment was considered gold standard for in vitro study.

Both in vivo and in vitro studies calculated the sensitivity, specificity and accuracy for detection of occlusal dental caries. In vivo study focused on detection (cut-off 20, 25, 30, 35) of non-cavitary or micro-cavitary occlusal caries extended in dentine (D3). In vitro study focused on detection (cut-off 10, 15, 20, 25, 30) of all dental caries (enamel, dentine). Both in vivo and in vitro studies aimed to determine optimal cut-off with highest accuracy value. Statistical analysis (McNemar test) was performed to determine significant statistical differences between the diagnosis accuracy of different cut-off laserfluorescence values.

The in vivo study also aimed to assess the posibility that Diagnodent values correlate with clinical depth. For this objective Spearman test was performed.

The accuracy of decisions of non-intervention, sealing and RPP was investigated, in relation to the real clinical depth of occlusal carious lesions.

Statistical analysis (McNemar test) was performed to determine significant statistical differences between the diagnosis accuracy of different cut-off laserfluorescence values.

All results were expressed as tables and graphs performed in Excel.

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RESULTS

In figures 39.a.-f. are presented clinical aspects and Diagnodent recordings of occlusal surfaces selected for in vitro study.

Fig.39.a. Aspect of questionable occlusal surfaces (3.8.). ICDAS 03.

Fig.39.b. Diagnodent 36. (dentine caries)

Fig.39.c. Histological aspect. Score D3.

Fig.39.d. Aspect of questionable occlusal surface (1.8.). ICDAS 04.

Fig.39.e. Diagnodent >30 (dentine caries)

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22

Fig.39.f. Histological aspect. Score D4.

In figures 40.a.-f. Are presented clinical aspect and Diagnodent recordings of occlusal surfaces selected for in vivo study.

Fig.40.a. T.E..Clinical aspect 4.7. ICDAS 02.

Fig.40.b. T.E. Diagnodent 17.(enamel caries)

Fig.40.c. T.E. Clinical aspect 4.7., after opening of carious lesion

Fig.40.d. N.D. Clinical aspect 1.6. ICDAS 04.

Fig.40.e. N.D.Diagnodent 29.

19

23

Fig.40.f. N.D. Clinical aspect 4.6. after opening of carious lesion The results regarding the distributions of ICDAS, Diagnodent values ranges, and Downer indices for in vivo and in vitro researches, are presented in figures 41.a-b, 42.a-b, 43.a-b.

Fig. 41.a. Distribution of ICDAS for in vivo study

Fig. 41.b. Distribution of ICDAS for in vitro study

Fig. 42.a. Distribution of Diagnodent values for in vivo study

3,85%

47,25%34,90%

14%

ICDAS 01

ICDAS 02

ICDAS 03

ICDAS 04

4,00%

72,00%

16,00%8.00%

ICDAS 01

ICDAS 02

ICDAS 03

ICDAS 04

5%

27%

23%15%

30% 10-19.

20-24

25-29

30-34

35-99

20

24

Fig. 42.b. Distribution of Diagnodent values for in vitro study

Fig. 43.a. Distribution of Downer indices for in vivo study

Fig. 43.b. Distribution of Downer indices for in vitro study

The results regarding distribution of ICDAS codes and Diagnodent values ranges

related to clinical depth (in vivo) and Downer indices (in vitro) are presented in fig. 44.a-b, 45.a-b.

.

20%

16%

8%24%

32% 0-9.10-14.15-19.20-24.25-99.

10,50%15,47%

62,80%

11,60%

D1

D2

D3

D4

20.00%

12,00%

24,00%

36,00%

8.00%D0

D1

D2

D3

D4

21

25

Fig.44.a. ICDAS related to clinical depth (in vivo)

Fig.44.b. ICDAS related to Downer indices (in vitro)

Fig.45.a. Diagnodent values related to clinical depth (in vivo)

Fig.45

0%

20%

40%

60%

80%

100%

D1 D2 D3 D4 D1 D2 D3 D4 D1 D2 D3 D4 D1 D2 D3 D4

ICDAS 01 ICDAS 02 ICDAS 03 ICDAS 04

100%

0%0%0%

14%17%

69%

0%0%

20%

73%

7%0%0%

9%

91%

0%

20%

40%

60%

80%

100%

D0 D2 D4 D1 D3 D0 D2 D4 D1 D3

ICDAS 01 ICDAS 02 ICDAS 03 ICDAS 04

100%

0%0%0%0%

29%22%16%

33%

0%0%0%

25%

50%

25%

0%0%0%

50%50%

0%

20%

40%

60%

80%

100%

D0 D2 D4 D1 D3 D0 D2 D4 D1 D3 D0 D2 D4

DD 0-19 DD 20-24 DD 25-29 DD 30-34 DD 35-99

0%0%0%

100%

0%0%

33%43%

24%

0%0%5%15%

80%

0%0%0%0%

66%

33%

0%0%0%

79%

21%

0%

20%

40%

60%

80%

D0 D2 D4 D1 D3 D0 D2 D4 D1 D3 D0 D2 D4

DD 0-9 DD 10-14 DD 15-19 DD 20-24. DD 25-99

80%

20%

0%0%0%

25%25%

50%

0%0%0%

50%50%

0%0%0%0%0%

66%

33%

0%0%

50%50%

0%

22

26

The distribution of Diagnodent values related to ICDAS codes are presented in fig.46.a-b.

Fig.46.a. Diagnodent values related to ICDAS (in vivo)

Fig.46.b. Diagnodent values related to ICDAS (in vitro) The results regarding sensitivity, specificity, accuracy for in vivo and in vitro researches are presented in fig.47.a-d. and 48.a-d.

Fig.47.a. Sensitivity for D3 (in vivo)

0%20%40%60%80%

100%

DD 0-19 DD 20-24 DD 25-29 DD 30-34 DD 35-99

0%0%

100%

0%14%

66%

19%0%0%

40%46%

14%0%

25%42%33%

0%

45%38%17%

0%20%40%60%80%

100%

DD 0-9 DD 10-14 DD 15-19 DD 20-24 DD 25-99

20%

100%

0%0%0%

100%

0%0%0%

100%

0%0%0%

82%

18%0%0%

38%38%24%

0

0,2

0,4

0,6

0,8

1

DD 20 DD 25 DD 30 DD 35

0,93 0,860,69

0,54

SENSIBILITATE (D3)

23

27

Fig.47.b. Specificity for D3 (in vivo)

Fig.47.c. Accuracy for D3 (in vivo)

Fig.47.d. Sensitivity, specificity, accuracy for cut-off DD 25 (in vivo)

0

0,2

0,4

0,6

0,8

1

DD 20 DD 25 DD 30 DD 35

0,2

0,81 1SPECIFICITATE (D3)

0

0,2

0,4

0,6

0,8

1

DD 20 DD 25 DD 30 DD 35

0,75 0,830,73

0,6

ACURATETE (D3)

0%

20%

40%

60%

80%

100%

SE SP AC

0,86 0,8 0,83D3 (DD25)

24

28

Fig.48.a.Sensitivity for D1 (in vitro)

Fig.48.b.Specificity for D1 (in vitro)

Fig.48.c. Accuracy for D1 (in vitro)

Fig.48.d. Sensitivity, specificity, accuracy for optimal cut-off (DD 10, in vitro)

0

0,5

1

DD 10 DD 15DD 20

DD 25

0,950,8 0,7

0,4

SENSIBILITATE (D1)

0

0,5

1

DD 10 DD 15DD 20

DD 25

0,8 1 1 1

SPECIFICITATE (D1)

0

0,5

1

DD 10 DD 15DD 20

DD 25

0,92 0,84 0,760,52

ACURATETE (D1)

0,7

0,8

0,9

1

SESP

AC

0,95

0,80,92

D1 (DD10)

25

29

For statistical analysis, test McNemar was performed (tabel 63.b.). Table 63.b. Test Mc Nemar.(in vivo; cut-off 20 vs. 25 vs. 30 vs. 35)

Test Statisticsc DD20accuracy

&

DD25accuracy

DD20accuracy

&

DD30accuracy

DD20accuracy

&

DD35accuracy

DD25accuracy

&

DD30accuracy

DD25accuracy

&

DD35accuracy

DD30accuracy

&

DD35accuracy N 78 78 78 78 78 78 Chi-Squarea .000 2.881 17.926

Asymp. Sig. 1.000 .090 .000

Exact Sig. (2-tailed) .027b .007b .000b a. Continuity Corrected b. Binomial distribution used. c. McNemar Test

Null hypothesis was invalidated; there are significant statistical differences between cut-off 25 and 20(Exact Sig. (2-tailed)), 25 and 30(Exact Sig. (2-tailed)) .

The results regarding accuracy of therapeutical decisions, for DD <10-healthy enamel, DD 10-24/enamel caries, DD 25/dentinal caries, are presented in figures 49.a-c.

Fig.49.a. Accuracy for decision of non-intervention (cut-off 10)

0%10%20%30%40%50%60%70%80%90%

100%

80%100%

80%

20% 20%

Non-interventie Cariismalt (D1-D2)

Non-interventieSanatos (D0)

26

30

Fig.49.b. Acurracy for sealing decisions (Diagnodent 0-24)

Fig.49.c. Acurracy for RPP therapeutical decisions (cut-off 25) CONCLUSIONS

Diagnodent values 20-24 are associated with enamel caries in 76% cases and with dentinal caries in 24% cases. Diagnodent values 25-29 are associated with enamel caries in 20% cases and with dentinal caries in 80% cases. Diagnodent values over 30 are associated in 66% cases with dentine demineralisation in external third and in 33% cases with dentine demineralisation in dentine medium third.

Laserfluorescence method has sensitivity values for enamel occlusal caries detection as follows: 0.95 for cut-off 10, 0.80 for cut-off 15, 0.70 for cut-off 20, 0.40 for cut-off 20.

Laserfluorescence method has sensitivity values for dentine occlusal caries detection as follows: 0.93 for cut-off 20, 0.86 for cut-off 25, 0.69 for cut-off 30, 0.54 for cut-off 35.

Cut-off has highest accuracy in detection of dentinal occlusal caries (0.83). Combination of visual method with laserfluorescence method provide optimal

therapeutic decisions in 80% cases for non-intervention, 72% cases for sealing, 80% cases for RPP.

0%

20%

40%

60%

80%

100%

8% 20% 6%

66%43% 66%

25% 37% 25%

Sigilare Cariidentinare (D3-D4)

Sigilare Carii smalt(D1-D2)

Sigilare Sanatos (D0)

0%10%20%30%40%50%60%70%80%

DD 25 ICDAS 03 DD 25 + ICDAS 03

0%

20%

80%

0%

25%

75%

0%

20%

80%

27

31

CHAPT.X. STUDY REGARDING CURRENT APPROACHES IN DIAGNOSTIC AND THERAPEUTICAL MANAGEMENT OF OCCLUSAL CARIES AIM OF STUDY. The study aimed to determine the current approaches of dentists in Iassy, regarding diagnostic and therapeutical management of incipient occlusal dental caries. MATERIALS AND METHODS.

A number of 80 dentists, working in private practice offices, responded to a list of 18 questions focused on diagnostic and therapeutical attitude in incipient occlusal dental caries. The results were related to total number of subjects and to experience (<5 years, 5-10 years, >10 years) and were expressed as graphs performed in Excel.

RESULTS 1.In what percentages do you use only visual method in the assessment of occlusal dental surfaces?

a. 100%; b.25-75%; c.<25%; d.0%

Fig. 51.a. Distribution in study group 2.In what percentages do you use only clinical examen in the assessment of dental occlusal surfaces?

a.100%; b.25-75%; c.<25%; d.0%

Fig. 52.a. Distribution in study group

0,00%

10,00%

20,00%

30,00%

40,00%

50,00%

100%. 25-75%. <25%. 0%.

2,50%

17,50%

35%45%

0%

20%

40%

60%

80%

100%. 25-75%. <25%. 0%.

8%

67%

15% 10%

28

32

3.In what percentages do you use air dry to detect incipient occlusal dental caries? a. 100%; b.25-75%; c.<25% ; d.0%

Fig. 53.a. Distribution in study group 4.In what percentages do you use radiographic examen to diagnose incipient occlusal dental caries? a. 100%; b.25-75%; c.<25%; d.0%

Fig. 54.a. Distribution in study group 5. What kind of radiographic examen do you use most frequently to diagnose incipient dental caries? a. Panoramic; b.Periapical; c. Byte-wing


0%

20%

40%

60%

80%

100%. 25-75%. <25%. 0%.

75%

20%5% 0

0%

10%

20%

30%

40%

50%

100%. 25-75%. <25%. 0%.

10%

37,50%45%

7,50%

0%10%20%30%40%50%60%

20%52%

28%

29

33

6. do you recommend byte-wing? a.100%; b. 25-75%; c. <25%; d. 0%

Fig. 56.a. Distribution in study group 7. What knowledges do you have about laserfluorescence method (Diagnodent)? a.Nothing; b. Partially; c. Complete knowledges.

Fig. 57.a. Distribution in study group 8. Did you used Diagnodent previously? a. Yes; b.No


00,10,20,30,40,50,6

100%. 25-75%. <25%. 0%.

012,50%

55%

32,50%

0%10%20%30%40%50%60%70%

Nu cunosc Cunostiinteaprofundate

5%

62,50%

32,50%

0,00%

50,00%

100,00%

DA NU

17,50%

82,50%

30

34

9. Do you consider useful the purchase of Diagnodent in next 5 years? a. Yes; b.No

Fig. 59.a. Distribution in study group THERAPEUTICAL MANAGEMENT

1. Do you consider cariogenic risk in therapeutical decisions regarding incipient occlusal dental caries ?

a. Yes; b.No


0,00%

20,00%

40,00%

60,00%

80,00%

DA NU

72,50%

27,50%

0%

50%

100%

DA NU

85%

15%

31

35

2. If your decision is not influenced by cariogenic risk, what do you preffer to use for patients with intact enamel with occlusal colorations? a. Non-intervention; b. Glassionomer sealing; c.Flow composite resin sealing; d.RPP; e.Hybrid composit resins filling

Fig. 61.a. Distribution in study group 3. If do you consider cariogenic risk, what do you preffer for low cariogenic risk patients and intact occlusal enamel with colour changes? a. Non-intervention; b. Glassionomer sealing; c.Flow composite resin sealing; d.RPP; e.Hybrid composit resins filling .


0%5%

10%15%20%25%30%35%40%

40%

0%

40%

20%

0%

0%5%

10%15%20%25%30%35%40%

37%

8%13%

39%

3%

32

36

4. If you consider cariogenic risk, what do you preffer for patients with high cariogenic risk and intact occlusal enamel with colour changes? a. Non-intervention; b. Glassionomer sealing; c.Flow composite resin sealing; d.RPP; e.Hybrid composit resins filling

Fig. 63.a. Distribution in study group 5. If you are not influenced in your therapeutical decisions by cariogenic risk, what do you preffer for patients with enamel breakdown and colour changes? a. Non-intervention; b. Glassionomer sealing; c.Flow composite resin sealing; d.RPP; e.Hybrid composit resins filling


0%5%

10%15%20%25%30%35%40%45%

11%6% 6%

34%43%

0%5%

10%15%20%25%30%35%

0% 0%

33% 33% 33%

33

37

6. If you consider cariogenic risk, what do you preffer for low cariogenic patients with enamel breakdown and colour changes? a. Non-intervention; b. Glassionomer sealing; c.Flow composite resin sealing; d.RPP; e.Hybrid composit resins filling

Fig. 65.a. Distribution in study group 7. If you consider cariogenic risk, what do you preffer for high cariogenic risk patients with occlusal enamel breakdown and colour changes? a. Non-intervention; b. Glassionomer sealing; c.Flow composite resin sealing; d.RPP; e.Hybrid composit resins filling


0%5%

10%15%20%25%30%35%40%45%50%

3%11% 9%

48%

29%

0%10%20%30%40%50%60%70%80%

0% 0%9%

20%

71%

34

38

CONCLUSIONS

Most incipient occlusal dental caries are detected and diagnosed during clinical examen.

If considered useful, periapical radiography is the most used radiographic method; byte-wing radiography is recommended by 28% dentists for incipient occlusal dental caries diagnosis.

72.50% dentists recognize the benfits of laserfluorescence method . 85% dentists integrate cariogenic risk category in therapeutical decisions regarding

dental caries. When non-cavitary occlusal dental caries are detected: for low cariogenic risk

patients, non-intervention and sealing with flow composite resin are most recommended; for high cariogenic risk patients, restorative treatments with hybrid composite resins are most applied therapeutical strategy.

When microcavitary occlusal dental caries are detected: for patients with low cariogenic risk , most used are RPP; for patients with high cariogenic risk, restorative treatments with hybrid composite resins are the election solution.

35

39

GENERAL CONCLUSIONS Prevalence of incipient occlusal dental caries is 31.30% (repported to total number of

occlusal surfaces). Prevalence of incipient occlusal dental caries is related to cariogenic risk category:

18,75% for low cariogenic risk, 32,10% for medium cariogenic risk, 37,1% for high cariogenic risk.

The distribution of ICDAS codes is influenced by cariogenic risk category, with significant statistical differences between low cariogenic risk and medium cariogenic risk, low cariogenic risk and high cariogenic risk.

ICDAS 02 and 03 are associated especially with low cariogenic risk and medium cariogenic risk, ICDAS 04 is mostly associated with high cariogenic risk.

Maxillary molars are most affected by incipient occlusal dental caries, followed by mandibular molars, maxillary bicusps and mandibular bicusps.

Enamel surfaces affected by incipient carious lesions are associated with high loss of Ca, P ions; significant statistical differences were demonstrated between demineralised enamel areas and healthy enamel. Significant statistical differences between white-spot and brown-spot carious lesions are recorded regarding Ca, P levels, with higher levels in brown-spot areas.

Each white-spot and brown-spot lesion presents minimal demineralisation area and maximal demineralisation area, with significant statistical differences regarding Ca, P content.

The areas with minimal demineralisation from white-spot and brown-spot carious lesions do not present significant statistical differences regarding Ca, P levels.

Byte-wing radiography detects 27% enamel radiotranslucencies and 26.75% dentinal radiotranslucencies (D1-D2).

Enamel rradiotranslucency is associated in 66% percentages with dentine demineralisation; radiotranslucency in dentine external third is associated in 90% percentages with dentine demineralisation; radiotranslucency in dentine medium third is associated in 100% percentages with dentine demineralisation.

Byte-wing examen used in diagnosis of incipient occlusal dental caries, has 0.44 sensitivity, 0.90 specificity and 0.57 accuracy.

No significant statistical differences were demonstrated between radiographic examen and visual examen regarding detection of incipient occlusal caries.

Diagnodent values 20-24 are associated with enamel caries in 76% cases and with dentinal caries in 24% cases. Diagnodent values 25-29 are associated with enamel caries in 20% cases and with dentinal caries in 80% cases. Diagnodent values over 30 are associated in 66% cases with dentine demineralisation in external third and in 33% cases with dentine demineralisation in dentine medium third.

Laserfluorescence has sensitivity values for enamel occlusal caries detection as follows: 0.95 for cut-off 10,0.80 for cut-off 15,0.70 for cut-off 20,0.40 for cut-off 20.

Laserfluorescence method has sensitivity values for dentine occlusal caries detection as follows: 0.93 for cut-off 20, 0.86 for cut-off 25, 0.69 for cut-off 30, 0.54 for cut-off 35.

Cut-off has highest accuracy in detection of dentinal occlusal caries (0.83). Combination of visual method with laserfluorescence method provide optimal

therapeutic decisions in 80% cases for non-intervention, 72% cases for sealing, 80% cases for RPP.

36

40

If considered useful, periapical radiography is the most used radiographic method; byte-wing radiography is recommended by 28% dentists for incipient occlusal dental caries diagnosis.

72.50% dentists recognize the benfits of laserfluorescence method . 85% dentists integrate cariogenic risk category in therapeutical decisions regarding

dental caries. When non-cavitary occlusal dental caries are detected: for low cariogenic risk

patients, non-intervention and sealing with flow composite resin are most recommended; for high cariogenic risk patients, restorative treatments with hybrid composite resins are most applied therapeutical strategy.

When microcavitary occlusal dental caries are detected: for patients with low cariogenic risk , most used are RPP; for patients with high cariogenic risk, restorative treatments with hybrid composite resins are the election solution.

37

41

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