Clinical evaluation of protocols in management of incipient caries lesions in adults

Objectives. The principles of modern caries management include detection and long-term monitoring of incipient non cavitated caries lesions; evaluation of patient's caries risk and effort to reduce the risk as well as caries management by applying less invasive treatment options and always according to the caries risk profile of each patient. The treatment of patients should focus mainly on prevention (using high fluoride toothpastes, solutions, patient education, etc) and avoid further invasive treatments, achieving thus the goal of modern dentistry, which follows the philosophy of minimal intervention. The effort of balancing the causative factors of caries with the protective factors in conjunction with caries risk assessment offers the ability to focus on the patient for the prevention and treatment before there is an irreversible lesion on dental tissues. For the application of modern caries management and treatment today, it is necessary to clinically apply a proper cost-effective prevention program on incipient caries lesions, according to minimally invasive principles, which guides the dentist beyond the theory, in the clinical practice.The aim of this study was to investigate the management of incipient carious lesions in adults with two preventive protocols. Different protocols were applied, based on the caries risk of each patient. The protocols for the management of incipient caries lesions evaluated in this clinical study include preventive and minimally invasive methods as published at the most recent studies of incipient lesions treatment. Moreover, the present in vivo study assessed detection ability of the Vista Proof and DIAGNOdent pen device at the incipient occlusal caries lesions of permanent teeth. Methods. A total of 50 adult patients of high, moderate and low caries risk with 516 incipient caries took part in the present study. These patients were assessed for caries with ICDAS criteria and were then divided into 3 groups depending on their caries risk profile: a high risk, a moderate risk and a low caries risk group. Participants in each group were further divided randomly into 2 subgroups (intervention group and control group). In intervention subgroups an intensive preventive protocol was applied while in control subgroups the protocol consisted only of instructions for oral hygiene. The invasive-intensive protocol included the topical application of fluoride, brushing with 5000ppm fluoride toothpaste, use of ACP-CPP, applications of sealants at occlusal lesions ICDAS code 2 and minimal resin restorations at occlusal lesions ICDAS code 3. In the control group and in the intervention group, recalls were performed at time intervals according to the caries risk of each patient. High risk patients were re-examined every 3 months, moderate risk every 6 months and low risk at 1 year. At the recalls, each lesion treated or not, was re-evaluated by the clinical ICDAS criteria (pit and fissures caries, root caries, caries on smooth surfaces, proximal surfaces). Moreover pit and fissures caries were evaluated with diagnostic devices. The treatment and the control groups were compared and the development of lesions was evaluated. Additionally, the diagnostic capacity of Vista Proof ™ and DIAGNOdent pen ™ devices was evaluated in relation to Visual examination with ICDAS II clinical criteria.The percentage and absolute number of incipient lesions in all groups at baseline examination and at the one year recall as well as the DMFS index for each group, were calculated. The changes for each lesion from the baseline examination to the one year recall were recorded. The non-parametric WILCOXON statistic test was applied in the two visits (baseline and one year) in each group for number of lesions comparison. Sensitivity, specificity, area under the ROC curve (Az values) at D1 threshold were calculated for the detection methods (Vistaproof and Diagnodentpen) independently in the annual recall. D1 threshold was used as lesions were incipient and ICDAS measurements were inferior to 4. Finally the agreement (ICC-Intraclass correlation coefficient) was calculated between diagnostic methods.ResultsΤhere was no statistically significant difference in the number of lesions (baseline and after 1 year) within the high-risk and moderate-risk groups that received the intensive protocol, while the control groups were statistically significant different. In patients with moderate caries risk, the intervention group presented lower caries development Rates, lower DMFS index than the control group. In patients with high caries risk the control group presented significant lower DMFS than the intervention group. The control group in patients with high caries risk presented overall better results than the intervention group. In low caries risk group there was no statistically significant difference in the number of lesions. Regarding the caries diagnostic devices at the one year recall, sensitivity and specificity found 0.61 and 0.51 for Diagnodent while sensitivity and specificity of VistaProof device was 0.64 and 0.54, respectively. The different detection methods showed no differences in diagnostic capacity (Az values) and ICC values were found very low.ConclusionsThe two different preventive protocols in high and moderate caries risk groups presented differences in effectiveness. In patients with moderate caries risk oral hygiene instructions given to the control group are not adequate to control caries. In patients with high caries risk, the result of this study is not clear. The control group presented overall better results than the intervention group however some incipient lesions further progressed into dentin in the control group, a fact that did not exist in the intervention group. Thus in high caries risk patients due to the above mentioned result the dentist must choose whether to apply to the patient an intensive protocol, however the risk of some incipient lesions to progress into dentin must be considered. In such cases the final selection should be done in collaboration with the patient and the cost-effectiveness should be taken into account. Regarding the low caries risk patients, both protocols proved to have no difference in results, meaning that in these patients the application only of oral hygiene instructions is adequate for the management of the incipient lesions.Incipient lesions in patients should be monitored regularly as the present study showed that these lesions are possible to advance in less than a year to a “worse” category (as evaluated with ICDAS criteria).Regarding the devices this study showed that they could be used only as an auxiliary tool in the clinical examination for monitoring occlusal lesions.Σκοπός. Ο σκοπός της παρούσας μελέτης ήταν η αξιολόγηση δύο προληπτικών προγραμμάτων για την διαχείριση των αρχόμενων τερηδονικών βλαβών σε ενήλικες. Μέθοδοι. Πενήντα ενήλικες ασθενείς υψηλού, μέσου και χαμηλού τερηδονικού κινδύνου με 516 αρχόμενες τερηδονικές αλλοιώσεις έλαβαν μέρος στην παρούσα μελέτη. Αυτοί οι ασθενείς αξιολογήθηκαν με τα ICDAS κριτήρια και με τις διαγνωστικές συσκευές Vista Proof™ και DIAGNOdent pen™ και στη συνέχεια χωρίστηκαν σε 3 ομάδες ανάλογα με τον τερηδονικό τους κίνδυνο: σε μια ομάδα υψηλού τερηδονικού κινδύνου, μια ομάδα μέσου κινδύνου και μια ομάδα χαμηλού τερηδονικού κινδύνου. Οι συμμετέχοντες σε κάθε ομάδα περαιτέρω χωρίστηκαν τυχαία σε 2 υποομάδες (ομάδα παρέμβασης και ομάδα ελέγχου).Στις υποομάδες παρέμβασης εφαρμόστηκε ένα εντατικό προληπτικό πρωτόκολλο ενώ στις υποομάδες ελέγχου το πρωτόκολλο περιελάμβανε μόνο οδηγίες στοματικής υγιεινής. Το πρωτόκολλο στις ομάδες παρέμβασης περιελάμβανε την τοπική εφαρμογή φθορίου, βούρτσισμα με οδοντόκρεμα 5000ppm φθορίου, χρήση ACP-CPP, εφαρμογές ΚΟΣ-sealants στις μασητικές αλλοιώσεις με κωδικό 2 κατά τα ICDAS II κριτήρια και αποκαταστάσεις με σύνθετη ρητίνη στις μασητικές αλλοιώσεις με κωδικό 3 κατά ICDAS II. Έγινε σύγκριση των 2 ομάδων -της ομάδας θεραπείας και της ομάδας ελέγχου- και αξιολόγηση της εξέλιξης των βλαβών. Επίσης αξιολογήθηκε η ικανότητα διάγνωσης των συσκευών Vista Proof™ και DIAGNOdent pen™ σε σχέση με την οπτική παρατήρηση, με βάση τα ICDAS II κλινικά κριτήρια. Αποτελέσματα. Δεν βρέθηκε στατιστικά σημαντική διαφορά στον αριθμό των βλαβών (στην αρχική εξέταση και μετά από 1 έτος) στις ομάδες υψηλού κινδύνου και μέσου τερηδονικού κινδύνου που εφαρμόστηκαν τα εντατικά πρωτοκόλλα, ενώ στις αντίστοιχες ομάδες ελέγχου βρέθηκαν στατιστικά σημαντικές διαφορές. Στην ομάδα χαμηλού τερηδονικού κινδύνου δεν υπήρχε στατιστικά σημαντική διαφορά στον αριθμό των βλαβών. Όσον αφορά τις διαγνωστικές συσκευές οι διαφορετικοί μέθοδοι ανίχνευσης των τερηδονικών βλαβών δεν παρουσίασαν διαφορές ως προς την ικανότητα διάγνωσης.Συμπεράσματα Τα δύο διαφορετικά προληπτικά πρωτόκολλα παρουσίασαν διαφορές στην αποτελεσματικότητα στις ομάδες υψηλού και μέσου τερηδονικού κινδύνου. Όσον αφορά τους ασθενείς χαμηλού τερηδονικού κινδύνου, η εφαρμογή οδηγιών στοματικής υγιεινής είναι ουσιώδης για τη διαχείριση των αρχόμενων βλαβών. Όσον αφορά τις συσκευές η παρούσα μελέτη έδειξε ότι θα μπορούσαν να χρησιμοποιηθούν μόνο σαν βοηθητικό εργαλείο στην κλινική εξέταση για την παρακολούθηση μασητικών αλλοιώσεων