JDR Clinical & Translational Research

The objective of this study was to identify the diagnostic capability of photostimulable phosphor plates (PSPs) and direct digital sensors (DDSs) in the detection of interproximal caries. Studies were identified that evaluated the diagnostic capability of PSPs and DDSs in detecting interproximal caries in human teeth, in both dentin and enamel. Histologic sections were the gold standard. This systematic review searched several electronic databases. In addition, Google Scholar and reference lists of the finally included studies were screened. QUADAS-2 was applied to evaluate the risk of bias among included studies. Six studies were finally included; 4 of which were considered homogeneous enough to conduct a meta-analysis. The meta-analysis evaluated 668 interproximal human tooth surfaces. All studies used extracted human teeth ranging from no caries present to caries into dentin. Each tooth was radiographed by both PSP and DDS technologies and then submitted for histologic analysis as the gold standard. Meta-analysis showed that intraoral digital imaging is of high specificity but low sensitivity in the detection of interproximal caries. The sensitivity and specificity for different studies with PSPs varied substantially from 15% to 54% and from 84% to 100%, respectively. Direct sensor analysis sensitivity and specificity ranged from 16% to 56% and from 90% to 100%, respectively. Newer PSP and DDS technologies had statistically significant higher sensitivities, yet the differences in diagnostic capabilities between the older and newer technologies were clinically insignificant. Both digital systems were excellent in identifying surfaces without caries (specificity) but were not sensitive enough to reliably identify interproximal surfaces with caries. Clinicians must therefore remain vigilant in performing a careful clinical examination and other diagnostic tests rather than relying solely on radiographic imaging to diagnose interproximal caries.

Knowledge Transfer Statement: This study will help clinicians make an evidence-based decision when deciding which digital radiography system to use when evaluating interproximal caries. Time, patient radiation safety, cost, and image quality are factors to be considered. The performance of the different available digital imaging systems was compared with the current gold standard—a histologic analysis—via meta-analysis.

Globally, dental caries is one of the most prevalent diseases and is more common in children living in deprived areas. Dental caries is preventable, and guidance in the United Kingdom recommends parental supervised brushing (PSB): a collection of behaviors—including twice-daily toothbrushing with fluoridated toothpaste—that should begin upon eruption of the first tooth (approximately 6 to 12 mo of age) and for which children need to be helped or supervised by an adult until at least 7 y of age. The aim of this study was to explore parents’ experiences of toothbrushing with their young children and to establish barriers and facilitators to PSB at individual, interpersonal, and environmental levels according to the theoretical domains framework. Qualitative semistructured interviews guided by the framework were conducted with 27 parents of young children (<7 y) in 2 deprived areas of the United Kingdom. Framework analysis was used. Parents were not aware of national guidance concerning their active involvement in toothbrushing; however, they did have detailed knowledge of toothbrushing practices for children, and their intentions were to brush their children’s teeth themselves twice every day as part of a family routine. Nonetheless, parents’ difficulties experienced in managing their children’s challenging behavior and the environmental context of their stressful lives meant that many parents adopted a role of simply reminding their children to brush or watching them brush. As such, the main barriers to PSB among parents living in deprived areas were skills in managing their children’s behavior and environmental influences on family life. The results of our study have clear implications for the development of appropriate interventions to address the modifiable barriers to improve parental adoption of PSB.

Knowledge Transfer Statement: The results of this study will be used to develop a behavior change intervention to encourage parental supervised brushing. The intervention—which is likely to be delivered through health practitioners rather than dental teams—will be developed to reduce dental caries among young children and will require evaluation in terms of its clinical and cost effectiveness.

Caries risk assessment (CRA) is widely recommended for dental caries management. Little is known regarding how practitioners use individual CRA items to determine risk and which individual items independently predict clinical outcomes in children younger than 6 y. The objective of this study was to assess the relative importance of pediatric CRA items in dental providers’ decision making regarding patient risk and in association with clinically evident caries, cross-sectionally and longitudinally. CRA information was abstracted retrospectively from electronic patient records of children initially aged 6 to 72 mo at a university pediatric dentistry clinic (n = 3,810 baseline; n = 1,315 with follow-up). The 17-item CRA form included caries risk indicators, caries protective items, and clinical indicators. Conditional random forests classification trees were implemented to identify and assign variable importance to CRA items independently associated with baseline high-risk designation, baseline evident tooth decay, and follow-up evident decay. Thirteen individual CRA items, including all clinical indicators and all but 1 risk indicator, were independently and statistically significantly associated with student/resident providers’ caries risk designation. Provider-assigned baseline risk category was strongly associated with follow-up decay, which increased from low (20.4%) to moderate (30.6%) to high/extreme risk patients (68.7%). Of baseline CRA items, before adjustment, 12 were associated with baseline decay and 7 with decay at follow-up; however, in the conditional random forests models, only the clinical indicators (evident decay, dental plaque, and recent restoration placement) and 1 risk indicator (frequent snacking) were independently and statistically significantly associated with future disease, for which baseline evident decay was the strongest predictor. In this predominantly high-risk population under caries-preventive care, more individual CRA items were independently associated with providers’ risk determination than with future caries status. These university dental providers considered many items in decision making regarding patient risk, suggesting that, in turn, these comprehensive CRA forms could also aid individualized care, linking risk assessment to disease management.

Knowledge Transfer Statement: Caries risk assessment (CRA) is widely recommended for patient-tailored, prevention-focused caries management. Studies show mixed predictive performance of pediatric CRA instruments, but little is known regarding how information captured in CRA forms guides clinical decision making. This study, in high-caries prevalence 6- to 72-mo-olds, demonstrates the following: 1) most items in a CRA instrument were independently associated with practitioners’ risk designations, 2) practitioners’ risk designations were significantly associated with future disease, and 3) of baseline measures associated with future caries, evident decay was the strongest independent indicator of future caries status. Although current disease (resulting from existing pathological and protective factor imbalance) may sufficiently predict future caries status in populations, other CRA items incorporated during risk categorization could aid practitioners to develop individualized intervention strategies against identified risk factors.

Different regimens of silver diamine fluoride (SDF) have been used to manage early childhood caries. So far, there is limited information regarding the concentrations and frequency of applications for effective caries control in primary teeth. This study aimed to compare the efficacy of 2 commercially available SDF solutions at preprepared concentrations of 38% and 12% when applied annually or biannually over 18 mo in arresting dentine caries in primary teeth. This randomized double-blinded clinical trial recruited kindergarten children aged 3 to 4 y who had at least 1 tooth with dentine caries. The children were randomly allocated to receive 4 treatment protocols: group 1, annual application of 12% SDF; group 2, biannual application of 12% SDF; group 3, annual application of 38% SDF; and group 4, biannual application of 38% SDF. Clinical examinations at 6-mo intervals were conducted to assess whether active carious lesions became arrested. Information on the children’s background and oral hygiene habits was collected through a parental questionnaire at baseline and follow-up examinations. A total of 888 children with 4,220 dentine carious tooth surfaces received treatment at baseline. After 18 mo, 831 children (94%) were examined. The caries arrest rates were 50%, 55%, 64%, and 74% for groups 1, 2, 3, and 4, respectively ( P < 0.001). Lesions treated with SDF biannual application had a higher chance of becoming arrested compared with those receiving SDF annual application (odds ratio, 1.33; 95% confidence interval, 1.04–1.71; P = 0.025). The interaction between concentration and lesion site was statistically significant ( P < 0.001). Compared with 12% SDF, the use of 38% SDF increased a chance of becoming arrested ( P < 0.05), except lesions on occlusal surfaces. Based on the 18-mo results, SDF is more effective in arresting dentin caries in the primary teeth of preschool children at 38% concentration than 12% concentration and when applied biannually rather than annually.

Knowledge Transfer Statement: The results of this study can be used by clinicians and dental public health professionals when deciding which concentrations and frequency of application of silver diamine fluoride solution should be adopted for arresting dentine caries. With consideration of caries arrest treatment with silver diamine fluoride, which is painless, simple, and low cost, this information could lead to more appropriate therapeutic decisions for caries control in young children or those who lack access to affordable conventional dental care.

The aim of this study was to estimate the relieving effect of music intervention on preoperative anxiety by using heart rate variability (HRV) analysis. In this randomized controlled trial, 86 adult patients were scheduled to undergo impacted tooth extraction under intravenous sedation and local anesthesia and were classified as either fearful or nonfearful based on a questionnaire. Thereafter, the patients were subdivided into 2 groups: those who listened to music from the time that they arrived at the outpatient clinic until immediately before entering the operating room and those who did not listen to music. The effect of music intervention was evaluated by assessing 1) the low-frequency/high-frequency ratio of HRV, in which positive changes indicate increased sympathetic nervous activity, and 2) the coefficient of component variance for high frequency, in which positive changes indicate increased parasympathetic nervous activity, assessed by means of HRV analysis. Subjective preoperative anxiety was evaluated on a visual analog scale. For fearful patients, the mean magnitude of low-frequency/high frequency changes from baseline among those who listened to music was significantly lower as compared with those who did not listen to music (in the private room: −1.45 ± 1.88 vs. 1.05 ± 1.88, P = 0.0096, 95% confidence interval of effect size = −4.52 to −0.48, Cohen’s d = −0.75; in the operating waiting room: −2.18 ± 2.39 vs. −0.10 ± 3.37, P = 0.011, 95% confidence interval of effect size = −3.94 to −0.22, Cohen’s d = −0.71, respectively). Visual analog scale scores were also significantly different. Coefficient of component variance for high frequency and heart rate did not differ significantly between the 2 groups. From the perspective of autonomic nervous activity, music intervention is useful for relieving anxiety in patients with dental fear before they enter a dental outpatient operating room. Music intervention may relieve anxiety by reducing sympathetic nervous activity, while parasympathetic nervous activity is not involved (UMIN000016882).

Knowledge Transfer Statement: The results of this study revealed that music intervention is useful for clinicians when planning preoperative anxiety management of patients with dental fear who undergo impacted tooth extraction under intravenous sedation and local anesthesia. As a bridging intervention, music intervention enables stress management to continue uninterrupted from the patient’s arrival at the dental outpatient clinic to intravenous sedation until completion of the dental surgery. With consideration of cost-effectiveness, absence of adverse physical effects, immediate effect, safety in terms of not using drugs, and lack of concerns about recovery, this information could lead to more appropriate decisions regarding anxiety management in dentistry.

An increasing body of evidence suggests a significant genetic regulation of inflammatory response mechanisms; however, little is known regarding the genetic determinants of severe gingival inflammation (GI). We conducted a genome-wide association study of severe GI among 4,077 European American adults, participants in the Dental Atherosclerosis Risk in Communities cohort. The severe GI trait was defined dichotomously with the 90th percentile of gingival index ≥2 extent score. Genotyping was performed with the Affymetrix 6.0 array platform, and an imputed set of 2.5 million markers, based on HapMap Phase II CEU build 36, was interrogated. Genetic models were based on logistic regression and controlled for ancestry (10 principal components), sex, age, and examination center. One locus on chromosome 17 met genome-wide statistical significance criteria—lead single-nucleotide polymorphism: rs11652874 (minor allele frequency = 0.06, intronic to ASIC2 [acid-sensing ionic channel 2, formerly named ACCN1]; odds ratio = 2.1, 95% confidence interval = 1.6 to 2.7, P = 3.9 × 10^-8). This association persisted among subjects with severe periodontitis and was robust to adjustment for microbial plaque index. Moreover, the minor (G) allele was associated with higher levels of severe GI in stratified analyses among subsets of participants with high load of either “red” or “orange” complex pathogens, although this association was not statistically significant. While these results will require replication in independent samples and confirmation by mechanistic studies, this locus appears as a promising candidate for severe GI. Our findings suggest that genetic variation in ASIC2 is significantly associated with severe GI and that the association is plaque independent.

Knowledge Transfer Statement: Persistent gingival inflammation reflected by bleeding usually precedes ongoing attachment loss or periodontal disease progression. Our findings suggest that genetic variation in ASIC2 that is associated with severe gingival inflammation might be used as a genetic marker to identify people at higher risk for periodontal disease. Ongoing studies to uncover the mechanistic link between ASIC2 and gingival inflammation could lead to novel therapeutic interventions.

Oxidative stress has been implicated in the pathogenesis of breast cancer (BC). To determine whether BC is associated with altered salivary redox homeostasis, we performed a case-control study assessing the relationship between BC and 8-oxo-7-hydrodeoxyguanosine (8-oxodG), a marker for oxidative damage to DNA. Enzyme-linked immunosorbent assay for 8-oxodG was used on whole, unstimulated saliva of 134 BC patients and 226 healthy controls. Associations of the redox data were assessed by analysis of variance and logistic regression analysis. Our results revealed that there were 1) significantly lower mean levels of salivary 8-oxodG in BC patients versus controls ( P = 0.0005), 2) significantly lower levels among participants who did not receive radiotherapy and/or chemotherapy as compared with controls ( P < 0.0001), 3) significantly lower levels among BC patients who did not receive these treatments than among those who did ( P < 0.02), 4) and no significant differences in mean 8-oxodG levels among BC patients positive or negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 ( P ≥ 0.08). Our results suggest that BC is associated with decreased levels of oxidatively modified DNA in saliva.

Knowledge Transfer Statement: The results of our current case-control study indicate that the molecular biomarker of oxidative stress 8-oxo-7-hydrodeoxyguanosine, measured from saliva, is associated with breast cancer. Our findings may provide the basis for future studies on molecular biomarkers of oxidative stress and breast cancer using saliva as an accessible and noninvasive tissue.

Long-lasting numbness of soft tissues such as lips, tongue, and cheeks after dental anesthesia is not only unpleasant but has the potential to cause self-inflicted damage to the numb tissue. Phentolamine mesylate, when injected in vicinity to the site of local anesthesia, accelerates the absorption of local anesthesia. Dental use of this drug was approved in the United States and Canada in 2008 and 2014, respectively. The rapidly increasing popularity of this novel technology (intraoral phentolamine injections) warrants a health technology assessment for clinicians. A medical librarian conducted a systematic literature search (up to March 1, 2016) for any clinical study involving intraoral phentolamine injection. Meta-analysis of the efficacy data from 4 clinical studies supports the role of intraoral phentolamine injections in shortening the duration of numbness after local anesthesia. No publication bias was found in the selected studies. The selected studies identified no serious adverse events other than pain at the site of injection and some postprocedural pain. Our cost-effectiveness analysis shows phentolamine mesylate to be an effective treatment modality when compared with no treatment, sham, or placebo injection. Phentolamine mesylate incurs an additional cost (in US dollars) of $0.13 to $0.16 per minute of reversing the soft tissue local anesthesia and $0.38 to $0.46, when compared with sham or placebo injection, after a noninvasive dental procedure. The literature lacked substantial evidence in favor of clinical benefits, such as a decrease in self-inflicted injuries. Only a subgroup of the dental patient population undergoing specific dental procedures would benefit from accelerated recovery from numbness.

Knowledge Transfer Statement: Intraoral phentolamine to reverse numbness is a new intervention with ambiguous utility. With consideration of cost and patient preference, evidence generated by this report may be used in clinical decision making and case selection for this intervention.