Bader JD, Shugars DA, Rozier G, et al. Diagnosis and Management of Dental Caries. Evidence Report/Technology Assessment No. 36 (prepared by Research Triangle Institute and University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-97-0011). AHRQ Publication No. 01-E056. Rockville, MD: Agency for Healthcare Research and Quality. June 2001.
Dental caries is a widespread chronic infectious disease, experienced by almost 80 percent of children by the age of 18 and over 90 percent of adults. Substantial variation exists in dentists’ diagnoses of carious lesions as well as in the methods dentists use to prevent and manage carious lesions. In addition, new methods for identifying carious lesions are beginning to appear, and new approaches for the management of individual carious lesions and for the management of individuals deemed to be at elevated risk for experiencing carious lesions are emerging. A systematic review of the literature was conducted to address three related questions concerning the diagnosis and management of dental caries: (1) the performance (sensitivity, specificity) of currently available diagnostic methods for carious lesions, (2) the efficacy of approaches to the management of noncavitated, or initial carious lesions, and (3) the efficacy of preventive methods in individuals who have experienced or are expected to experience elevated incidence of carious lesions.
We conducted two detailed searches of the relevant English language literature from 1966 to October 1999 using MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. We did not pursue reports in the gray literature, i.e., information not appearing in the periodic scientific literature. We did hand-search current journals up to the end of 1999. One search focused on six diagnostic methods (visual and visual/tactile inspection, radiography, fiberoptic transillumination, electrical conductance, laser fluorescence) and combinations of these methods. A second search focused on preventive or management methods for carious lesions, including fluorides, pit and fissure sealants, health education, dental prophylaxis, oral hygiene, dental plaque, chlorhexidine, dental sealants, and cariostatic agents.
We included studies in the diagnostic review that used histologic validation of caries status and either reported results as sensitivity and specificity of the diagnosis or reported data from which these measures could be calculated. We excluded reports of diagnostic methods not commercially available. For the review of the dental caries management literature, we included only reports concerning methods applied or prescribed in a professional setting. Also, we included only studies performed in vivo and having a comparison group. In the literature describing the management of noncavitated carious lesions, we included only studies where the lesion was the unit of analysis. In the literature describing the management of subjects at elevated risk for dental caries, we included only studies where such determinations had been made on an individual subject level based on carious lesion experience and/or bacteriologic testing.
Data Collection and Analysis
We selected studies for inclusion from among 1,407 diagnostic and 1,478 management reports through independent duplicate reviews of titles, abstracts, and, where necessary, full papers. We abstracted data (single abstraction, subsequent independent review) on 39 diagnostic studies and 27 management studies using different forms for the diagnostic and management studies. Similarly, a separate quality rating form was completed by the scientific director for the each study. Different rating forms were employed for the two types of studies.
We judged the strength of the evidence describing the validity of all diagnostic methods evaluated to be poor. There were almost no reports of diagnostic performance of any method applied to primary teeth, anterior teeth, and root surfaces. For posterior occlusal and proximal surfaces of permanent teeth, the number of available studies was sufficient for some but not all methods. However, where numbers of studies were sufficient, their quality and/or the variation among studies precluded establishing unambiguous assessments of sensitivity and specificity. The variation in sensitivity among methods was generally similar to the variation reported within methods. With the exception of electrical conductance, dental caries diagnostic methods featured criteria that maximized specificity at the expense of sensitivity: false positive diagnoses were proportionally infrequent compared with false negative diagnoses. In addition to the limited numbers of studies for certain teeth and methods, the literature on diagnosis displayed a variety of serious limitations, including the predominance of in vitro studies, small numbers of examiners, high prevalences of lesions, and inadequate descriptions of subject selection, examiner training and reliability, and criteria for diagnoses.
The literature on the management of noncavitated carious lesions consisted of five studies describing seven experimental interventions. Because these interventions varied extensively in terms of management methods tested as well as other study characteristics, no conclusions about the efficacy of these methods were possible. We rated the evidence for efficacy of methods for the management of noncavitated lesions as incomplete. Standardization for the determination of noncavitated status is needed for future studies.
The literature on the management of individuals at elevated risk of carious lesions consisted of 22 studies describing 29 experimental interventions. We rated the evidence for the efficacy of fluoride varnish for prevention of dental caries in high-risk subjects as fair and the evidence for all other methods as incomplete. Because the evidence for efficacy for some methods, including chlorhexidine, sucrose-free and xylitol-containing gum, and combined chlorhexidine-fluoride methods, is suggestive but not conclusive, these interventions represent fruitful areas for further research.
The strength of the evidence available to estimate the validity of diagnostic methods for carious lesions dental caries is insufficient to the task. For many applications, there are few studies, and when sufficient numbers of studies are available, substantial variation among studies and/or the quality of the studies is problematic.
The literature describing the management of two specific dental caries-related conditions, nonsurgical interventions for noncavitated lesions and prevention of lesions in persons at elevated risk for new lesions, is inadequate to permit conclusions about the efficacy of most methods. Only for two specific applications, fluoride varnishes in caries-active, high-risk individuals and fluoride-based interventions for individuals receiving radiotherapy was the evidence rated as fair. For all other management methods, the evidence was judged to be incomplete. The need for efficacy determinations is acute as much of modern preventive dental practice is predicated on the efficacy of management methods for these conditions.