Dundee Dental Hospital

This paper describes early findings of evaluations of the International Caries Detection and Assessment System (ICDAS) conducted by the Detroit Center for Research on Oral Health Disparities (DCR-OHD). The lack of consistency among the contemporary criteria systems limits the comparability of outcomes measured in epidemiological and clinical studies. The ICDAS criteria were developed by an international team of caries researchers to integrate several new criteria systems into one standard system for caries detection and assessment. Using ICDAS in the DCR-OHD cohort study, dental examiners first determined whether a clean and dry tooth surface is sound, sealed, restored, crowned, or missing. Afterwards, the examiners classified the carious status of each tooth surface using a seven-point ordinal scale ranging from sound to extensive cavitation. Histological examination of extracted teeth found increased likelihood of carious demineralization in dentin as the ICDAS codes increased in severity. The criteria were also found to have discriminatory validity in analyses of social, behavioral and dietary factors associated with dental caries. The reliability of six examiners to classify tooth surfaces by their ICDAS carious status ranged between good to excellent (kappa coefficients ranged between 0.59 and 0.82). While further work is still needed to define caries activity, validate the criteria and their reliability in assessing dental caries on smooth surfaces, and develop a classification system for assessing preventive and restorative treatment needs, this early evaluation of the ICDAS platform has found that the system is practical; has content validity, correlational validity with histological examination of pits and fissures in extracted teeth; and discriminatory validity.

Oral potentially malignant disorders (OPMDs) are associated with an increased risk of occurrence of cancers of the lip or oral cavity. This paper presents an updated report on the nomenclature and the classification of OPMDs, based predominantly on their clinical features, following discussions by an expert group at a workshop held by the World Health Organization (WHO) Collaborating Centre for Oral Cancer in the UK. The first workshop held in London in 2005 considered a wide spectrum of disorders under the term "potentially malignant disorders of the oral mucosa" (PMD) (now referred to as oral potentially malignant disorders: OPMD) including leukoplakia, erythroplakia, proliferative verrucous leukoplakia, oral lichen planus, oral submucous fibrosis, palatal lesions in reverse smokers, lupus erythematosus, epidermolysis bullosa, and dyskeratosis congenita. Any new evidence published in the intervening period was considered to make essential changes to the 2007 classification. In the current update, most entities were retained with minor changes to their definition. There is sufficient evidence for an increased risk of oral cancer among patients diagnosed with "oral lichenoid lesions" and among those diagnosed with oral manifestations of 'chronic graft-versus-host disease'. These have now been added to the list of OPMDs. There is, to date, insufficient evidence concerning the malignant potential of chronic hyperplastic candidosis and of oral exophytic verrucous hyperplasia to consider these conditions as OPMDs. Furthermore, due to lack of clear evidence of an OPMD in epidermolysis bullosa this was moved to the category with limited evidence. We recommend the establishment of a global research consortium to further study the natural history of OPMDs based on the classification and nomenclature proposed here. This will require multi-center longitudinal studies with uniform diagnostic criteria to improve the identification and cancer risk stratification of patients with OPMDs, link them to evidence-based interventions, with a goal to facilitate the prevention and management of lip and oral cavity cancer.

BACKGROUND: Topically-applied fluoride varnishes have been used extensively as an operator-applied caries-preventive intervention for over three decades. This review updates the first Cochrane review of fluoride varnishes for preventing dental caries in children and adolescents, which was first published in 2002. OBJECTIVES: To determine the effectiveness and safety of fluoride varnishes in preventing dental caries in children and adolescents, and to examine factors potentially modifying their effect. SEARCH METHODS: We searched the Cochrane Oral Health Group's Trials Register (to 13 May 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 4), MEDLINE via OVID (1946 to 13 May 2013), EMBASE via OVID (1980 to 13 May 2013), CINAHL via EBSCO (1980 to 13 May 2013), LILACS and BBO via the BIREME Virtual Health Library (1980 to 13 May 2013), ProQuest Dissertations and Theses (1861 to 13 May 2013), and Web of Science Conference Proceedings (1945 to 13 May 2013). A search for ongoing trials was undertaken on ClinicalTrials.gov on 13 May 2013. There were no restrictions on language or date of publication in the search of the electronic databases. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials with blind outcome assessment used or indicated, comparing topically-applied fluoride varnish with placebo or no treatment in children up to 16 years during at least one year. The main outcome was caries increment measured by the change in decayed, missing and filled tooth surfaces in both permanent (D(M)FS) and primary (d(e/m)fs) teeth. DATA COLLECTION AND ANALYSIS: At least two review authors assessed all search results, extracted data and undertook risk of bias independently. Study authors were contacted for additional information. The primary measure of effect was the prevented fraction, that is the difference in mean caries increments between the treatment and control groups expressed as a percentage of the mean increment in the control group. The caries increments nearest to three years were used from each included study. Random-effects meta-analyses were performed where data could be pooled. Potential sources of heterogeneity were examined in random-effects meta-regression analyses. Adverse effects information was collected from the included trials. MAIN RESULTS: Twenty-two trials with 12,455 participants randomised (9595 used in analyses) were included. For the 13 that contributed data for the permanent tooth surfaces meta-analysis, the pooled D(M)FS prevented fraction estimate comparing fluoride varnish with placebo or no treatment was 43% (95% confidence interval (CI) 30% to 57%; P < 0.0001). There was substantial heterogeneity, confirmed statistically (P < 0.0001; I(2) = 75%), however this body of evidence was assessed as of moderate quality. The pooled d(e/m)fs prevented fraction estimate was 37% (95% CI 24% to 51%; P < 0.0001) for the 10 trials that contributed data for the primary tooth surfaces meta-analysis, also with some heterogeneity (P = 0.009; I(2) = 59%). Once again this body of evidence was assessed as of moderate quality. No significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the pre-specified factors of baseline caries severity, background exposure to fluorides, application features such as prior prophylaxis, concentration of fluoride, frequency of application were found. There was also no significant association between estimates of D(M)FS or d(e/m)fs prevented fractions and the post hoc factors: whether a placebo or no treatment control was used, length of follow-up, or whether individual or cluster randomisation was used, in the meta-regression models. A funnel plot of the trials in the main meta-analyses indicated no clear relationship between prevented fraction and study precision. In both methods, power is limited when few trials are included. There was little information concerning possible adverse effects or acceptability of treatment. AUTHORS' CONCLUSIONS: The conclusions of this updated review remain the same as those when it was first published. The review suggests a substantial caries-inhibiting effect of fluoride varnish in both permanent and primary teeth, however the quality of the evidence was assessed as moderate, as it included mainly high risk of bias studies, with considerable heterogeneity.

Reporting the economic burden of oral diseases is important to evaluate the societal relevance of preventing and addressing oral diseases. In addition to treatment costs, there are indirect costs to consider, mainly in terms of productivity losses due to absenteeism from work. The purpose of the present study was to estimate the direct and indirect costs of dental diseases worldwide to approximate the global economic impact. Estimation of direct treatment costs was based on a systematic approach. For estimation of indirect costs, an approach suggested by the World Health Organization's Commission on Macroeconomics and Health was employed, which factored in 2010 values of gross domestic product per capita as provided by the International Monetary Fund and oral burden of disease estimates from the 2010 Global Burden of Disease Study. Direct treatment costs due to dental diseases worldwide were estimated at US$298 billion yearly, corresponding to an average of 4.6% of global health expenditure. Indirect costs due to dental diseases worldwide amounted to US$144 billion yearly, corresponding to economic losses within the range of the 10 most frequent global causes of death. Within the limitations of currently available data sources and methodologies, these findings suggest that the global economic impact of dental diseases amounted to US$442 billion in 2010. Improvements in population oral health may imply substantial economic benefits not only in terms of reduced treatment costs but also because of fewer productivity losses in the labor market.

BACKGROUND: Clinical trials have shown the benefits of cholinesterase inhibitors for the treatment of mild-to-moderate Alzheimer's disease. It is not known whether treatment benefits continue after the progression to moderate-to-severe disease. METHODS: We assigned 295 community-dwelling patients who had been treated with donepezil for at least 3 months and who had moderate or severe Alzheimer's disease (a score of 5 to 13 on the Standardized Mini-Mental State Examination [SMMSE, on which scores range from 0 to 30, with higher scores indicating better cognitive function]) to continue donepezil, discontinue donepezil, discontinue donepezil and start memantine, or continue donepezil and start memantine. Patients received the study treatment for 52 weeks. The coprimary outcomes were scores on the SMMSE and on the Bristol Activities of Daily Living Scale (BADLS, on which scores range from 0 to 60, with higher scores indicating greater impairment). The minimum clinically important differences were 1.4 points on the SMMSE and 3.5 points on the BADLS. RESULTS: Patients assigned to continue donepezil, as compared with those assigned to discontinue donepezil, had a score on the SMMSE that was higher by an average of 1.9 points (95% confidence interval [CI], 1.3 to 2.5) and a score on the BADLS that was lower (indicating less impairment) by 3.0 points (95% CI, 1.8 to 4.3) (P<0.001 for both comparisons). Patients assigned to receive memantine, as compared with those assigned to receive memantine placebo, had a score on the SMMSE that was an average of 1.2 points higher (95% CI, 0.6 to 1.8; P<0.001) and a score on the BADLS that was 1.5 points lower (95% CI, 0.3 to 2.8; P=0.02). The efficacy of donepezil and of memantine did not differ significantly in the presence or absence of the other. There were no significant benefits of the combination of donepezil and memantine over donepezil alone. CONCLUSIONS: In patients with moderate or severe Alzheimer's disease, continued treatment with donepezil was associated with cognitive benefits that exceeded the minimum clinically important difference and with significant functional benefits over the course of 12 months. (Funded by the U.K. Medical Research Council and the U.K. Alzheimer's Society; Current Controlled Trials number, ISRCTN49545035.).

BACKGROUND: Corticosteroids and antiviral agents are widely used to treat the early stages of idiopathic facial paralysis (i.e., Bell's palsy), but their effectiveness is uncertain. METHODS: We conducted a double-blind, placebo-controlled, randomized, factorial trial involving patients with Bell's palsy who were recruited within 72 hours after the onset of symptoms. Patients were randomly assigned to receive 10 days of treatment with prednisolone, acyclovir, both agents, or placebo. The primary outcome was recovery of facial function, as rated on the House-Brackmann scale. Secondary outcomes included quality of life, appearance, and pain. RESULTS: Final outcomes were assessed for 496 of 551 patients who underwent randomization. At 3 months, the proportions of patients who had recovered facial function were 83.0% in the prednisolone group as compared with 63.6% among patients who did not receive prednisolone (P<0.001) and 71.2% in the acyclovir group as compared with 75.7% among patients who did not receive acyclovir (adjusted P=0.50). After 9 months, these proportions were 94.4% for prednisolone and 81.6% for no prednisolone (P<0.001) and 85.4% for acyclovir and 90.8% for no acyclovir (adjusted P=0.10). For patients treated with both drugs, the proportions were 79.7% at 3 months (P<0.001) and 92.7% at 9 months (P<0.001). There were no clinically significant differences between the treatment groups in secondary outcomes. There were no serious adverse events in any group. CONCLUSIONS: In patients with Bell's palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone. (Current Controlled Trials number, ISRCTN71548196 [controlled-trials.com].).

The International Caries Consensus Collaboration undertook a consensus process and here presents clinical recommendations for carious tissue removal and managing cavitated carious lesions, including restoration, based on texture of demineralized dentine. Dentists should manage the disease dental caries and control activity of existing cavitated lesions to preserve hard tissues and retain teeth long-term. Entering the restorative cycle should be avoided as far as possible. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. Only when cavitated carious lesions either are noncleansable or can no longer be sealed are restorative interventions indicated. When a restoration is indicated, the priorities are as follows: preserving healthy and remineralizable tissue, achieving a restorative seal, maintaining pulpal health, and maximizing restoration success. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralized tissues close to the pulp do not need to be removed. In deeper lesions in teeth with sensible (vital) pulps, preserving pulpal health should be prioritized, while in shallow or moderately deep lesions, restoration longevity becomes more important. For teeth with shallow or moderately deep cavitated lesions, carious tissue removal is performed according toselective removal to firm dentine.In deep cavitated lesions in primary or permanent teeth,selective removal to soft dentineshould be performed, although in permanent teeth,stepwise removalis an option. The evidence and, therefore, these recommendations support less invasive carious lesion management, delaying entry to, and slowing down, the restorative cycle by preserving tooth tissue and retaining teeth long-term.

BACKGROUND: Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers). OBJECTIVES: To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment. SEARCH STRATEGY: Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. SELECTION CRITERIA: Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer. DATA COLLECTION AND ANALYSIS: Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random-effects models. MAIN RESULTS: A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta-analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte-colony stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate. AUTHORS' CONCLUSIONS: Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

BACKGROUND: Dental plaque associated gingivitis is a reversible inflammatory condition caused by accumulation and persistence of microbial biofilms (dental plaque) on the teeth. It is characterised by redness and swelling of the gingivae (gums) and a tendency for the gingivae to bleed easily. In susceptible individuals, gingivitis may lead to periodontitis and loss of the soft tissue and bony support for the tooth. It is thought that chlorhexidine mouthrinse may reduce the build-up of plaque thereby reducing gingivitis. OBJECTIVES: To assess the effectiveness of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for the control of gingivitis and plaque compared to mechanical oral hygiene procedures alone or mechanical oral hygiene procedures plus placebo/control mouthrinse. Mechanical oral hygiene procedures were toothbrushing with/without the use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment.To determine whether the effect of chlorhexidine mouthrinse is influenced by chlorhexidine concentration, or frequency of rinsing (once/day versus twice/day).To report and describe any adverse effects associated with chlorhexidine mouthrinse use from included trials. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 28 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 8) in the Cochrane Library (searched 28 September 2016); MEDLINE Ovid (1946 to 28 September 2016); Embase Ovid (1980 to 28 September 2016); and CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 28 September 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials assessing the effects of chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for at least 4 weeks on gingivitis in children and adults. Mechanical oral hygiene procedures were toothbrushing with/without use of dental floss or interdental cleaning aids and could include professional tooth cleaning/periodontal treatment. We included trials where participants had gingivitis or periodontitis, where participants were healthy and where some or all participants had medical conditions or special care needs. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where feasible. For continuous outcomes, we used means and standard deviations to obtain the mean difference (MD) and 95% confidence interval (CI). We combined MDs where studies used the same scale and standardised mean differences (SMDs) where studies used different scales. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs. Due to anticipated heterogeneity we used random-effects models for all meta-analyses. MAIN RESULTS: We included 51 studies that analysed a total of 5345 participants. One study was assessed as being at unclear risk of bias, with the remaining 50 being at high risk of bias, however, this did not affect the quality assessments for gingivitis and plaque as we believe that further research is very unlikely to change our confidence in the estimate of effect. Gingivitis After 4 to 6 weeks of use, chlorhexidine mouthrinse reduced gingivitis (Gingival Index (GI) 0 to 3 scale) by 0.21 (95% CI 0.11 to 0.31) compared to placebo, control or no mouthrinse (10 trials, 805 participants with mild gingival inflammation (mean score 1 on the GI scale) analysed, high-quality evidence). A similar effect size was found for reducing gingivitis at 6 months. There were insufficient data to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 (moderate or severe levels of gingival inflammation). Plaque Plaque was measured by different indices and the SMD at 4 to 6 weeks was 1.45 (95% CI 1.00 to 1.90) standard deviations lower in the chlorhexidine group (12 trials, 950 participants analysed, high-quality evidence), indicating a large reduction in plaque. A similar large reduction was found for chlorhexidine mouthrinse use at 6 months. Extrinsic tooth staining There was a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 4 to 6 weeks. The SMD was 1.07 (95% CI 0.80 to 1.34) standard deviations higher (eight trials, 415 participants analysed, moderate-quality evidence) in the chlorhexidine mouthrinse group. There was also a large increase in extrinsic tooth staining in participants using chlorhexidine mouthrinse at 7 to 12 weeks and 6 months. Calculus Results for the effect of chlorhexidine mouthrinse on calculus formation were inconclusive. Effect of concentration and frequency of rinsing There were insufficient data to determine whether there was a difference in effect for either chlorhexidine concentration or frequency of rinsing. Other adverse effects The adverse effects most commonly reported in the included studies were taste disturbance/alteration (reported in 11 studies), effects on the oral mucosa including soreness, irritation, mild desquamation and mucosal ulceration/erosions (reported in 13 studies) and a general burning sensation or a burning tongue or both (reported in nine studies). AUTHORS' CONCLUSIONS: There is high-quality evidence from studies that reported the Löe and Silness Gingival Index of a reduction in gingivitis in individuals with mild gingival inflammation on average (mean score of 1 on the 0 to 3 GI scale) that was not considered to be clinically relevant. There is high-quality evidence of a large reduction in dental plaque with chlorhexidine mouthrinse used as an adjunct to mechanical oral hygiene procedures for 4 to 6 weeks and 6 months. There is no evidence that one concentration of chlorhexidine rinse is more effective than another. There is insufficient evidence to determine the reduction in gingivitis associated with chlorhexidine mouthrinse use in individuals with mean GI scores of 1.1 to 3 indicating moderate or severe levels of gingival inflammation. Rinsing with chlorhexidine mouthrinse for 4 weeks or longer causes extrinsic tooth staining. In addition, other adverse effects such as calculus build up, transient taste disturbance and effects on the oral mucosa were reported in the included studies.

This paper reviews the evidence that coronal leakage of root canals may lead to failure of root-canal therapy. The causes of coronal leakage and methods by which this leakage may be prevented are described.

Classical descriptive epidemiology in the field of cleft lip and palate aims to quantify the problem, and in the higher income countries it is possible to do this with varying degrees of accuracy. This is not however possible in every country in the world, and epidemiology should seek to identify these data gaps with a view to improvement in the situation. Epidemiology must also be investigative and look for trends, associations and inter-population differences, with the aim of supporting aetiological research and advancing the translational agenda. This chapter is set out in three parts and seeks to address all three of the above areas. Birth defects in general and orofacial clefting in particular remain a relatively common and significant problem for not only the individual patients born with these defects in terms of death or disability, but also for their families and for society in general in terms of burden of care and health inequality. In high-income countries, despite very significant advances in treatment, problems in access to care and evidence base for cleft care still exist whereas in the developing world the consequences are lack of access to care and lack of infrastructure to help with quantification of the problem and consequently the ability to address it. The major questions in contemporary cleft lip and palate research surround ways of improving the evidence base for the treatment interventions used to optimise quality of care, and the ultimate scientific and humanitarian objective is primary prevention of those diseases and disorders that are preventable. Descriptive epidemiology underpins research enquiry in both of these major areas.

Age and loss of teeth can be expected to have a complex relationship with oral health-related quality of life. This study aimed to explain how age and tooth loss affect the impact of oral health on daily living using the short form, 14-item Oral Health Impact Profile (OHIP-14) on national population samples of dentate adults from the UK (1998 UK Adult Dental Health Survey) and Australia (1999 National Dental Telephone Interview Survey). After correcting for key covariables, increasing age was associated with better mean impact scores in both populations. Those aged 30-49 years in Australia showed the worst (highest) scores. In the UK, those aged under 30 showed the highest scores. In both countries, adults aged 70+ showed much better scores than the rest (P < 0.001). When corrected for age, the independent effect of tooth loss was that the worst scores were found where there were fewer than 17 natural teeth in the UK and fewer than 21 teeth in Australia. People with 25 or more teeth averaged much better scores than all other groups (P < 0.001), although there were differences in pattern between countries. When Australians were analysed by region of birth, the pattern of scores by tooth loss for British/Irish immigrants was strikingly similar to that for the UK sample. First-generation immigrants from elsewhere showed much worse overall scores and a profoundly different pattern to the Australian- and British-born groups. Age, number of teeth and cultural background are important variables influencing oral health-related quality of life.

BACKGROUND: Dental caries is a major public health problem in most industrialised countries, affecting 60% to 90% of school children. Community water fluoridation was initiated in the USA in 1945 and is currently practised in about 25 countries around the world; health authorities consider it to be a key strategy for preventing dental caries. Given the continued interest in this topic from health professionals, policy makers and the public, it is important to update and maintain a systematic review that reflects contemporary evidence. OBJECTIVES: To evaluate the effects of water fluoridation (artificial or natural) on the prevention of dental caries.To evaluate the effects of water fluoridation (artificial or natural) on dental fluorosis. SEARCH METHODS: We searched the following electronic databases: The Cochrane Oral Health Group's Trials Register (to 19 February 2015); The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2015); MEDLINE via OVID (1946 to 19 February 2015); EMBASE via OVID (1980 to 19 February 2015); Proquest (to 19 February 2015); Web of Science Conference Proceedings (1990 to 19 February 2015); ZETOC Conference Proceedings (1993 to 19 February 2015). We searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization's WHO International Clinical Trials Registry Platform for ongoing trials. There were no restrictions on language of publication or publication status in the searches of the electronic databases. SELECTION CRITERIA: For caries data, we included only prospective studies with a concurrent control that compared at least two populations - one receiving fluoridated water and the other non-fluoridated water - with outcome(s) evaluated at at least two points in time. For the assessment of fluorosis, we included any type of study design, with concurrent control, that compared populations exposed to different water fluoride concentrations. We included populations of all ages that received fluoridated water (naturally or artificially fluoridated) or non-fluoridated water. DATA COLLECTION AND ANALYSIS: We used an adaptation of the Cochrane 'Risk of bias' tool to assess risk of bias in the included studies.We included the following caries indices in the analyses: decayed, missing and filled teeth (dmft (deciduous dentition) and DMFT (permanent dentition)), and proportion caries free in both dentitions. For dmft and DMFT analyses we calculated the difference in mean change scores between the fluoridated and control groups. For the proportion caries free we calculated the difference in the proportion caries free between the fluoridated and control groups.For fluorosis data we calculated the log odds and presented them as probabilities for interpretation. MAIN RESULTS: A total of 155 studies met the inclusion criteria; 107 studies provided sufficient data for quantitative synthesis.The results from the caries severity data indicate that the initiation of water fluoridation results in reductions in dmft of 1.81 (95% CI 1.31 to 2.31; 9 studies at high risk of bias, 44,268 participants) and in DMFT of 1.16 (95% CI 0.72 to 1.61; 10 studies at high risk of bias, 78,764 participants). This translates to a 35% reduction in dmft and a 26% reduction in DMFT compared to the median control group mean values. There were also increases in the percentage of caries free children of 15% (95% CI 11% to 19%; 10 studies, 39,966 participants) in deciduous dentition and 14% (95% CI 5% to 23%; 8 studies, 53,538 participants) in permanent dentition. The majority of studies (71%) were conducted prior to 1975 and the widespread introduction of the use of fluoride toothpaste.There is insufficient information to determine whether initiation of a water fluoridation programme results in a change in disparities in caries across socioeconomic status (SES) levels.There is insufficient information to determine the effect of stopping water fluoridation programmes on caries levels.No studies that aimed to determine the effectiveness of water fluoridation for preventing caries in adults met the review's inclusion criteria.With regard to dental fluorosis, we estimated that for a fluoride level of 0.7 ppm the percentage of participants with fluorosis of aesthetic concern was approximately 12% (95% CI 8% to 17%; 40 studies, 59,630 participants). This increases to 40% (95% CI 35% to 44%) when considering fluorosis of any level (detected under highly controlled, clinical conditions; 90 studies, 180,530 participants). Over 97% of the studies were at high risk of bias and there was substantial between-study variation. AUTHORS' CONCLUSIONS: There is very little contemporary evidence, meeting the review's inclusion criteria, that has evaluated the effectiveness of water fluoridation for the prevention of caries.The available data come predominantly from studies conducted prior to 1975, and indicate that water fluoridation is effective at reducing caries levels in both deciduous and permanent dentition in children. Our confidence in the size of the effect estimates is limited by the observational nature of the study designs, the high risk of bias within the studies and, importantly, the applicability of the evidence to current lifestyles. The decision to implement a water fluoridation programme relies upon an understanding of the population's oral health behaviour (e.g. use of fluoride toothpaste), the availability and uptake of other caries prevention strategies, their diet and consumption of tap water and the movement/migration of the population. There is insufficient evidence to determine whether water fluoridation results in a change in disparities in caries levels across SES. We did not identify any evidence, meeting the review's inclusion criteria, to determine the effectiveness of water fluoridation for preventing caries in adults.There is insufficient information to determine the effect on caries levels of stopping water fluoridation programmes.There is a significant association between dental fluorosis (of aesthetic concern or all levels of dental fluorosis) and fluoride level. The evidence is limited due to high risk of bias within the studies and substantial between-study variation.

The diagnosis of occlusal caries at non-cavitated sites remains problematic, especially since clinical visual detection has limited sensitivity. Electrical methods of detection show considerable promise, but specificity is reduced. The aims of this in vitro study were: (1) to assess the validity of a new laser fluorescence device--the DIAGNOdent--(and compare the values with those of a fixed-frequency electrical device); (2) to determine the optimum cut-off points of the new device for different stages of the caries process, and (3) to assess the reproducibility of the new laser device. For validity and determination of optimum cut-off points, 105 extracted teeth with macroscopically intact occlusal surfaces were measured by a single examiner, using both the laser fluorescence device (on both moist and dried teeth) and an Electronic Caries Monitor. The teeth were subsequently examined histologically to determine the specificity, sensitivity and likelihood ratio at the D2 (caries extending through more than half of the enamel thickness) and D3 (caries involving dentin) levels. The values obtained for the laser device ranged from 0.72 to 0.87 (specificity), 0.76 to 0.87 (sensitivity) and 3.0 to 5.6 (likelihood ratio). Those for the ECM ranged from 0.64 to 0.78 (specificity), 0. 87 to 0.92 (sensitivity) and 2.4 to 4.1 (likelihood ratio). To determine intra- and interexaminer reproducibility of the DIAGNOdent, 11 dentists recorded two different measurements at the same site on a separate set of 83 extracted molar teeth, and these were compared using Cohen's kappa (at D2 and D3 levels) and Spearman's correlation coefficient. The average intra-examiner kappa scores were 0.88 (D2) and 0.90 (D3), with a Spearman correlation of 0.97. For interexaminer reproducibility, the average kappa values were 0.65 (D2) and 0.73 (D3), with a Spearman correlation of 0.84. It is concluded that for occlusal caries (1) the new laser device has a higher diagnostic validity than the ECM, and (2) in vitro, measurements using the device are highly reproducible. Thus, the laser device could be a valuable tool for the longitudinal monitoring of caries and for assessing the outcome of preventive interventions.

Children and adolescents must be examined often for occlusal caries. Diagnosis of fissure caries is difficult especially when the tooth surface appears seemingly intact. It has been shown that using traditional clinical methods, as little as 20% of teeth with fissure caries under intact surfaces were correctly recognised as such. Therefore, new methods for increasing the accuracy of diagnosis have been sought for years. Recently, a new device, based on fluorescence measurements, was introduced. The purpose of this study was to test the device under in vivo conditions in order to provide recommendations for its use in the dental office. Seven general dental practitioners examined a total of 332 occlusal surfaces in 240 patients. Caries extent was determined for each site after operative intervention (='gold standard'). Clinical inspection and analysis of bitewing radiographs exhibited statistically significant lower sensitivities (31-63%) than did the DIAGNOdent device (sensitivity > or = 92%). It is recommended that the laser device is used in the decision-making process in relation to the diagnosis of occlusal caries as a second opinion in cases of doubt after visual inspection.

BACKGROUND: Ten percent of people may experience pain under the heel (plantar heel pain) at some time. Injections, insoles, heel pads, strapping and surgery have been common forms of treatment offered. The absolute and relative effectiveness of these interventions are poorly understood. OBJECTIVES: The objective of this review was to identify and evaluate the evidence for effectiveness of treatments for plantar heel pain. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (September 2002), the Cochrane Central Register of Controlled Trials Register (The Cochrane Library issue 3, 2002), MEDLINE (1966 to September 2002), EMBASE (1988 to September 2002) and reference lists of articles and dissertations. Four podiatry journals were handsearched to 1998. We contacted all UK schools of podiatry to identify dissertations on the management of heel pain, and investigators in the field to identify unpublished data or research in progress. No language restrictions were applied. SELECTION CRITERIA: Randomised and quasi-randomised trials of interventions for plantar heel pain in adults. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated randomised controlled trials for inclusion, extracted data and assessed trial quality. Additional information was obtained by direct contact with investigators. No poolable data were identified. Where measures of variance were available we have calculated the weighted mean differences based on visual analogue scale (VAS) scores. MAIN RESULTS: Nineteen randomised trials involving 1626 participants were included. Trial quality was generally poor, and pooling of data was not conducted. All trials measured heel pain as the primary outcome. Seven trials evaluated interventions against placebo/dummy or no treatment. There was limited evidence for the effectiveness of topical corticosteroid administered by iontophoresis, i.e using an electric current, in reducing pain. There was some evidence for the effectiveness of injected corticosteroid providing temporary relief of pain. There was conflicting evidence for the effectiveness of low energy extracorporeal shock wave therapy in reducing night pain, resting pain and pressure pain in the short term (6 and 12 weeks) and therefore its effectiveness remains equivocal. In individuals with chronic pain (longer than six months), there was limited evidence for the effectiveness of dorsiflexion night splints in reducing pain. There was no evidence to support the effectiveness of therapeutic ultrasound, low-intensity laser therapy, exposure to an electron generating device or insoles with magnetic foil. No randomised trials evaluating surgery, or radiotherapy against a randomly allocated control population were identified. There was limited evidence for the superiority of corticosteroid injections over orthotic devices. REVIEWER'S CONCLUSIONS: Although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in randomised controlled trials. At the moment there is limited evidence upon which to base clinical practice. Treatments that are used to reduce heel pain seem to bring only marginal gains over no treatment and control therapies such as stretching exercises. Steroid injections are a popular method of treating the condition but only seem to be useful in the short term and only to a small degree. Orthoses should be cautiously prescribed for those patients who stand for long periods; there is limited evidence that stretching exercises and heel pads are associated with better outcomes than custom made orthoses in people who stand for more than eight hours per day. Well designed and conducted randomised trials are required.

Variation in the terminology used to describe clinical management of carious lesions has contributed to a lack of clarity in the scientific literature and beyond. In this article, the International Caries Consensus Collaboration presents 1) issues around terminology, a scoping review of current words used in the literature for caries removal techniques, and 2) agreed terms and definitions, explaining how these were decided.Dental cariesis the name of the disease, and thecarious lesionis the consequence and manifestation of the disease-the signs or symptoms of the disease. The termdental caries managementshould be limited to situations involving control of the disease through preventive and noninvasive means at a patient level, whereascarious lesion managementcontrols the disease symptoms at the tooth level. While it is not possible to directly relate the visual appearance of carious lesions' clinical manifestations to the histopathology, we have based the terminology around the clinical consequences of disease (soft, leathery, firm, and hard dentine). Approaches to carious tissue removal are defined: 1)selective removal of carious tissue-includingselective removal to soft dentineandselective removal to firm dentine; 2)stepwise removal-including stage 1,selective removal to soft dentine, and stage 2,selective removal to firm dentine6 to 12 mo later; and 3)nonselective removal to hard dentine-formerly known ascomplete caries removal(technique no longer recommended). Adoption of these terms, around managing dental caries and its sequelae, will facilitate improved understanding and communication among researchers and within dental educators and the wider clinical dentistry community.

BACKGROUND: The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first published in 2006. OBJECTIVES: To assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth. SEARCH METHODS: The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 12 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 12 December 2012) and EMBASE via OVID (1980 to 12 December 2012). There were no restrictions regarding language or date of publication. SELECTION CRITERIA: Parallel group and split-mouth randomised and quasi-randomised controlled trials comparing stepwise, partial or no dentinal caries removal with complete caries removal, in unrestored primary and permanent teeth were included. DATA COLLECTION AND ANALYSIS: Three review authors extracted data independently and in triplicate and assessed risk of bias. Trial authors were contacted where possible for information. We used standard methodological procedures exacted by The Cochrane Collaboration. MAIN RESULTS: In this updated review, four new trials were included bringing the total to eight trials with 934 participants and 1372 teeth. There were three comparisons: stepwise caries removal compared to complete one stage caries removal (four trials); partial caries removal compared to complete caries removal (three trials) and no dentinal caries removal compared to complete caries removal (two trials). (One three-arm trial compared complete caries removal to both stepwise and partial caries removal.) Four studies investigated primary teeth, three permanent teeth and one included both. All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I(2) = 0%) compared to complete caries removal based on moderate quality evidence, with no heterogeneity. In these four studies, the mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I(2) = 0%).Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I(2) = 0%), also based on moderate quality evidence with no evidence of heterogeneity. In these two studies the mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I(2) = 0%, low quality evidence), or restoration failure (one study showing no difference and another study showing no failures in either group, very low quality evidence).No dentinal caries removal was compared to complete caries removal in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies. AUTHORS' CONCLUSIONS: Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

Abstract Background Chronic foot ulceration is a major source of morbidity in diabetic patients. Despite traditional comprehensive wound management, including vascular reconstruction, there remains a cohort of patients with non-responding wounds, often resulting in amputation. These wounds may benefit from molecular manipulation of growth factors to enhance the microcirculation. Methods A review of the current literature was performed using Pubmed, with secondary references obtained from key articles. Results and conclusion There has been a generally disappointing clinical outcome from growth factor trials, although topical platelet-derived growth factor has shown significant benefit and should be considered in non-healing, well perfused ulcers after failure of conventional wound care. The modulatory role of the extracellular matrix in the cellular response to growth factors and data from regenerative-type fetal wound healing are further areas of interest. The chemical induction of microvessel formation may become a future therapeutic option.

A barrier to providing sealants is concern about inadvertently sealing over caries. This meta-analysis examined the effectiveness of sealants in preventing caries progression. We searched electronic databases for comparative studies examining caries progression in sealed permanent teeth. We used a random-effects model to estimate percentage reduction in the probability of caries progression in sealed vs. unsealed carious teeth. Six studies, including 4 randomized-controlled trials (RCT) judged to be of fair quality, were included in the analysis (384 persons, 840 teeth, and 1090 surfaces). The median annual percentage of non-cavitated lesions progressing was 2.6% for sealed and 12.6% for unsealed carious teeth. The summary prevented fraction for RCT was 71.3% (95%CI: 52.8%-82.5, no heterogeneity) up to 5 years after placement. Despite variation among studies in design and conduct, sensitivity analysis found the effect to be consistent in size and direction. Sealing non-cavitated caries in permanent teeth is effective in reducing caries progression.