Caries Epidemiology

Sonia K. Makhija, DDS, MPH

Definitions related to Epidemiology

Epidemiology

Study of disease in populations Study of patterns, causes and control of disease in populations Study of the spread of diseases within and between populations

Definitions of Types of Epidemiologic Studies

Cohort (Longitudinal study) People assembled on the basis of a common characteristics and followed over time (caries rates in high-risk individuals); incidence Cross-sectional People assembled on the basis of a common characteristic and seen just one time (caries proportions in high-risk individuals); prevalence Case-Control Case: Person who has a particular disease or health condition Control: Person who does not have the condition being studied

Definition of Epidemiologic Measures

Prevalence
Probability of already having a disease No follow-up

Incidence
Probability of getting the disease in a given time period Requires follow-up of individuals

Depends on duration of disease (long duration increases prevalence)

Does not depend on duration of the disease

Measuring Disease DMFS/DMFT

DMFS: Decayed, Missing, Filled Surfaces DMFT: Decayed, Missing, Filled Teeth DMF index gives total caries experience of a person D is present, M is unknown, F is past Measurement of caries that is most widely used because it is simple, versatile, and reliable Almost outdated: ICDAS, active/inactive measurements being used more often

Problems in Measuring Caries

Diagnostic thresholds (loops, pressure of explorer, etc) Hidden caries (fluoride use has caused this to increase) Reversals (in incidence studies-had caries previously, but does not have caries now) Sub-gingival root caries

Limitations of DMF Index

Not related to the number of teeth at risk (no denominator) Gives equal weight to missing, decayed, restored teeth Invalid when teeth have been lost for reasons other than caries Overestimates caries experience with PRR or esthetics Composites hard to detect, can lead to underestimation Hard to compare two groups b/c there is no universal criterion for decayed (frank cavitation vs white lesion vs non-cavitated) Does not account for sealed teeth

Mean DMFT Scores by age in a Kenyan Population

16 14 12 Mean DMFT 10 8 6 4 2 0 12 15-24 25-34 35-44 45-54 55-65 Age group (years) Including Enamel Lesions Excluding Enamel Lesions

ICDAS-International Caries Detection and Assessment System

Scoring system used to record caries at all stages Has 6 stages coded 0-5 0 code is sound

Photos of ICDAS Codes Code 1

When seen wet there is no evidence of any change in color attributable to carious activity, but after prolonged air drying (approximately 5 s is suggested to adequately dehydrate a carious lesion in enamel) a carious opacity or discoloration (white or brown lesion) is visible that is not consistent with the clinical appearance of sound enamel OR When there is a change of color because of caries which is not consistent with the clinical appearance of sound enamel and is limited to the confines of the pit and fissure area (whether seen wet or dry).

Code 2
Distinct visual change in enamel The tooth must be viewed wet. When wet there is a (i) carious opacity (white spot lesion) and/or (ii) brown carious discoloration which is wider than the natural fissure/fossa that is not consistent with the clinical appearance of sound enamel (Note: the lesion must still be visible when dry)

Code 3
Localized enamel breakdown because of caries with no visible dentin or underlying shadow: The tooth viewed wet may have a clear carious opacity (white spot lesion) and/or brown carious discoloration which is wider than the natural fissure/fossa that is not consistent with the clinical appearance of sound enamel. Once dried for approximately 5 s there is carious loss of tooth structure at the entrance to, or within, the pit or fissure/fossa. This will be seen visually as evidence of demineralization [opaque (white), brown or dark brown walls] at the entrance to or within the fissure or pit and the dentin is NOT visible in the walls or base of the cavity/discontinuity. The WHO/CPI/PSR probe can be used gently across a tooth surface to confirm the presence of a cavity apparently confined to the enamel.

Code 4
Underlying dark shadow from dentin with or without localized enamel breakdown This lesion appears as a shadow of discolored dentin visible through an apparently intact enamel surface which may or may not show signs of localized breakdown (loss of continuity of the surface that is not showing the dentin). The shadow appearance is often seen more easily when the tooth is wet. The darkened area is an intrinsic shadow which may appear as grey, blue or brown in color. The shadow must clearly represent caries that started on the tooth surface being evaluated.

Code 5
Distinct cavity with visible dentin Cavitation in opaque or discolored enamel exposing the dentin beneath. The tooth viewed wet may have darkening of the dentin visible through the enamel. Once dried for 5 s there is visual evidence of loss of tooth structure at the entrance to or within the pit or fissure frank cavitation. There is visual evidence of demineralization [opaque (white), brown or dark brown walls] at the entrance to or within the pit or fissure and in the examiner judgment dentin is exposed.

Objective of Epidemiology: Determine Patterns of Disease in Different Populations

3 Patterns on Global Distribution of Caries

Rural China and Africa and remote areas of South America High mortality rate Poor infrastructure Water sources not protected, so risk of other diseases BUT Sugar not as available compared to urban areas; therefore caries more rampant in urban parts

3 Patterns on Global Distribution of Caries

Newly industrialized countries such as Taiwan, India, China, Chile, Uganda, and Thailand Increase in caries rate in children and adults Increase in rate of edentulousness This is thought to be due to an increase in urbanization in these areas, people switch from dependence on traditional starchy staple food to refined carbohydrates May not have access to care, but have access to cariogenic diet

3 Patterns on Global Distribution of Caries

North America, Australia, Europe and Japan Decreasing caries rates in children Increasing number of retained teeth in adults This is new change: post WWII brought economic prosperity, increase in sugar consumption, and increase in caries rates This rate has now decreased due to the advent of water fluoridation and changes in diet Development of high-speed handpieces and dental insurance helped older adults retain teeth

Increase in Caries Rate (DMFT) in 12-Year Olds

YEAR
1979-1992 1972-1994 1960-1991 1972-1992 1961-1993 1962-1995 1965-1983 1967-1993 1966-1992

COUNTRY
TAIWAN THAILAND CHILE MEXICO LEBANON JORDAN PERU INDIA UGANDA

DMFT
0.9-4.3 0.9-1.6 2.8-5.3 2.5-5.1 1.2-5.7 0.2-3.3 3.2-5.9 1.2-3.8 0.4-2.4

%CHANGE
+ 477 +177 +189 + 204 + 475 + 650 + 184 + 316 + 600

Decrease in Caries Rate (DMFT) in 12-Year Olds

YEAR
1982-1999 1980-2001 1982-1997 1987-1998 1982-1996 1984-2002 1984-1994 1981-1999 1987-1994

COUNTRY
Australia Denmark Finland France Iceland Ireland Spain Japan USA

DMFT Initial
3.0 5.0 4.0 4.2 8.3 3.3 4.2 5.4 1.8

DMFT Latest
0.8 0.9 1.1 1.9 1.5 1.3 2.3 2.4 1.3

Objective of Epidemiology: Determine Risk Factors of Disease

Some Risk Factors for Caries

Age Gender Race SES Genetics Diet

How would you treat this patient?

You must always take into account a patients risk assessment before you treat!

Low Risk
Clinical Conditions No decay in the past 24 months No enamel demineralization (white spot) No visible plaque; gingivitis

Moderate Risk
Decayed teeth in the past 24 months 1 area of enamel demineralization (white spot) Gingivitis

High Risk
Decayed teeth in the past 12 months More than 1 area of enamel demineralization (white spot) Visible plaque Ortho appliances Enamel hypoplasia Suboptimal fluoride exposure Frequent between-meal exposures to simple sugars Low-level socioeconomic status No routine dental care

Environmental Characteristics

Optimal systemic and topical fluoride exposure Consumption of simple sugars primarily at mealtime High socioeconomic status Regular dental care use

Suboptimal systemic fluoride with optimal topical exposure Occasional betweenmeal exposures to simple sugars Mid-level socioeconomic status Irregular dental care use

General Health Conditions

Xerostomia

Risk Factor: Age

Age: Mean DMF scores increase with age. Adolescents: this increase comes from an increase in restored teeth Adults: this increase comes from more missing teeth Caries viewed as a lifetime disease

Risk Factor: Gender

Gender Females have higher DMF score In children, this is due to earlier eruption in females Males have more untreated decay (higher D score) Females have more restored teeth (higher F score) Females aged 12-17 had the same mean DMF score as males, but 25% more filled surfaces

Risk Factor: Race and Ethnicity

Global variations in caries experience due more to environment Once certain groups move to a different area and experience different dietary patterns, their caries rates change There is some difference between Whites and AfricanAmericans, but mainly due to access to care. Whites had higher F and African-Americans had higher D DMF score of Mexican Americans was lower than national average, but D was higher Difference is SES rather than race or ethnicity (access to care)

Risk Factor: Socioeconomic Status

Measured by education, income, occupation, and place of residence 60-70% of all carious lesions found in 15-25% of population Higher SES had the sharpest decline in caries experience Tend to have fewer missing teeth and more filled surfaces

Mean DMFS scores for 15-year old children based on SES level in US, 1988-1994
7 6 5 M ean D M F S 4 3 2 1 0 Low Middle Socioeconomic Status Groups High Filled Missing Decayed

Risk Factor: Genetics Dental Caries and Treatment Characteristics in Human Twins Reared Apart
JP Conroy, LB Messer, JC Boraas, DP Aeppli, and TJ Bouchard Jr.

Introduction
Study involved twins reared apart, controlling for environmental influence Sets it apart from other twin studies Part of the Minnesota Study of Twins Reared Apart (MSTRA)

Materials and Methods

106 Monozygotic subjects and 72 dizygotic subjects participated in the study Mean age : 42.2 64% Females Mean age at time of separation: 5.7 months Mean time apart: 35.0 years From nine different countries

Sex, age, and measures of contact for MZ and DZ twins raised apart
Zygosity
Age (yr)

Female Male

Time together before sep (months)

Time from sep to reunion (yr)

% of life spent apart

MZ (106) Mean SD DZ (72) Mean SD All (178) Mean SD 42.2 13.9 43.8 13.6 40.4 14.1

64

42 4.2 7.4 31.5 14.5 40.3 12.4 35 14.3 96 97 95

50

22 7.9 9.6

114

64 5.7 8.5

Materials and Methods

Medical and dental history obtained Clinical exam preformed Radiographs and study models obtained from each participant Lesions recorded using mirror, explorer, and light

Analysis of Data
Assessed number of teeth present, number and designation of teeth restored, number and designation of surfaces restored, and number and designation of carious surfaces 7 pairs of MZ and 14 pairs of DZ were excluded due to edentulous arches

Results

Within each group, there was an association (highly significant) within the MZ group for all variables: dentate status, teeth present, teeth present excluding 3rd molars, treatment status, teeth restored, surfaces restored, and surfaces carious Within the DZ group there as no association within any of the variables

Discussion
Although reared apart, the MZ twins showed strong similarity in caries experience, proving a genetic component

Discussion
Genetics may influence behavior and dictate preferences in the oral cavity Twins had different standards of care and differing treatment philosophies, yet they had similar caries experience

Risk Factor: Diet

Major Study on Diet and Caries

Vipehlm Experimental study on the effect of diet on dental decay Conducted at a mental institution (unethical due to lack of informed consent) in Sweden between 19451952 Patients consumed varying amounts of candy with and during meals. Some had no added sugar to their diet, some had 24 sticky toffees a day, some during meals, some between meals. Compared these groups

Results from Vipehlm Study

Sugar consumption increases caries activity The risk of increased caries activity is greater if the sugar is in sticky form The increase in caries under uniform conditions shows great individual variation The increase in caries disappears on withdrawal of sticky foodstuffs from the diet Caries can still occur in the absence of refined sugar, natural sugars, and high total dietary carbohydrates

Results from a Major Epidemiologic Study

NHANES Data
National Health and Nutrition Examination Survey Determines prevalence Nationwide survey Findings from this survey will be used to determine the prevalence of major diseases and risk factors for diseases. NHANES findings are also the basis for national standards for such measurements as height, weight, and blood pressure.

Adolescents 12-18 Years Who Ever Had Caries in Permanent Teeth, 1988-94 and 1999-2000

Percent

80

1988-94

1999-2000

2010 Target

60

40

20

Total

White

Black

Mexican American

Female

Male

Note: Target is for adolescents 15 years old. Black and white exclude persons of Hispanic origin. Persons of MexicanAmerican origin may be any race. Source: National Health and Nutrition Examination Survey, NCHS, CDC.

Children 2-4 Years Who Have Ever Had Caries in Primary Teeth, 1988-94 and 1999-2000
Percent
50

1988-94

1999-2000 2010 Target

40

30

20

10

Total

White

Black

Mexican American

Female

Male

Note: Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race. Source: National Health and Nutrition Examination Survey, NCHS, CDC.

Oral Health Findings from NHANES

Untreated Decay in primary teeth (Age 211): 21% had untreated decay in their primary teeth. Fewer non-Hispanic white children (18%) and children from families with higher incomes (13%) had untreated tooth decay, compared with non-Hispanic black (27%) and Mexican-American (32%) children.

Oral Health Findings from NHANES

Untreated Decay (Age 619) 14% of children and adolescents had untreated tooth decay in their permanent teeth. The prevalence of untreated decay in the permanent teeth was 7% for children aged 611 years, 16% for adolescents 1215 years, and 22% for adolescents 1619 years Low-income children/adolescents (20%) had more than twice as much untreated decay as those from families with higher incomes (8%) Mexican-American and non-Hispanic black children (22% and 18%, respectively) had about twice as much decay as nonHispanic white children/adolescents (11%)

Oral Health Findings from NHANES

Dental Sealants (Age 619) There was a 64% increase in the percentage of children and adolescents who had received a dental sealant 32% of children had at least one dental sealant on one or more permanent molar, premolar, or upper lateral incisor, compared with 20% in the previous survey Half as many (22%) low-income children had received a dental sealant as children (42%) from higher income families

Dental Sealants: 1988-94 and 1999-2000

Percent
50 40 30 20 10 0
Total White Black Mexican American Total White Black Mexican American

1988-94 1999-2000 2010 Targets

1988-94 1999-2000

6-11 Years
Unreliable estimate, relative standard error >30%.

12-18 Years

Note: Targets are for children 8 years and 14 years. Black and white exclude persons of Hispanic origin. Persons of Mexican-American origin may be any race. Source: National Health and Nutrition Examination Survey, NCHS, CDC.

Oral Health Findings from NHANES

Fluorosis: 32% of children and adolescents aged 6 to 19 years had very mild or greater enamel fluorosis The prevalence of fluorosis was lowest among persons aged 2039 years (16%), 611 years (28%), 1619 years (32%), and followed by persons aged 1215 years (37%) Non-Hispanic blacks had the highest prevalence of fluorosis (33%), compared to non-Hispanic whites (20%)

Epidemiologic Studies done in Daily Clinical Practice: The Dental Practice-Based Research Network

The DPBRN regions

How many DPBRN practitioner-investigators are there?

Practitioner-investigators enrolled in DPBRN, meaning that an enrollment questionnaire has been completed: 822 from the AL/MS region 123 from the FL/GA region 54 from the HP/MN region 64 from the PDA region 60 from the SK region Total of 1,123; this includes general dentists, dental specialists, and dental hygienists

DPBRN Studies
Longitudinal Study of Questionable Occlusal Caries Lesions Peri-Operative Pain and Root Canal Therapy Persistent Pain and Root Canal Therapy Incidence of post-operative infection after oral osseous surgery Impact of dental practice-based research networks on patient care Blood sugar testing in dental practice Longitudinal Study of Repaired or Replaced Dental Restorations Hygienists' Internet Tobacco Cessation Study Reasons for Replacement or Repair of Restorations Patient Satisfaction with Dental Restorations Prevalence of Questionable Occlusal Caries Lesions Longitudinal Study of Dental Restorations Placed on Previously Unrestored Surfaces Development of a Patient-Based Provider Intervention for Early Caries Management Reasons for Placement of Restorations on Previously Unrestored Surfaces Retrospective Cohort Study of Osteonecrosis of the Jaws CONDOR Study of Osteonecrosis of the Jaws An Internet Intervention to Improve Oral Cancer Prevention Assessment of Caries Diagnosis and Caries Treatment Practice-Based Root Canal Treatment Effectiveness Among Diabetics and NonDiabetics

DPBRN Study: Prevalence of Questionable Occlusal Caries Lesions (QOC)

The progression of cavitated dental caries has slowed dramatically over the years, and the prevalence of precavitated lesions has significantly increased. Due to the size of these lesions, the ability to correctly diagnose and treat them can be difficult. Limited literature is available for these questionable lesions and the reasons behind why clinicians are having difficulty diagnosing and treating them. The objective of this study was to determine the regional variations in patients and practitioners who participated in The DPBRN study Prevalence of questionable occlusal caries lesions. QOC are defined as clinically-suspected caries with no cavitation or radiographic evidence of occlusal caries.

Examples of Questionable Occlusal Caries Lesions (QOC)

Photos courtesy of Dr. John Burgess

Consecutive Patient Log

Data Collection Form

Data Collection Form

Methods

81 DPBRN dentists and hygienists participated in the study. When a patient presented with at least 1 unrestored occlusal surface, the number of unrestored occlusal surfaces and QOC were quantified. Information was recorded on consented patients who presented with at least one QOC (up to 2 lesions/patient could be enrolled in the study): gender; race; ethnicity; age; dental insurance; tooth location and surface; and pre-and post-operative depth. Practitioner-investigators completed an enrollment questionnaire that included the dentists age, gender, practice workload, practice type, and years since graduation. Statistical significance was evaluated using chi-square to determine regional differences

Prevalence of QOC
AL/MS FL/GA MN PDA SK TOTAL

Practitioner/Patient Level
Number of Practitioners Specialty Type Gen. practice Pediatrics Pract. Type Dentist Hygienist

9/81

19/81

13/81

15/81

25/81

81

7 2 9 0

18 1 19 0

13 0 13 0

14 1 15 0

21 4 13 12

73 8 69 12

Patient/Tooth Level
Patient-level prevalence* QOC/number of patients Tooth-level prevalence* QOC/number of unrestored surfaces *p<0.001 357/911 (39%) 641/1,844 (35%) 379/1,113 (34%) 169/1,283 (13%) 755/2,526 (30%) 2,301/7,677 (30%)

688/6,910 (10%)

1,378/11,105 (12%)

689/7,435 (9%)

350/6,934 (5%)

1,709/18,061 (10%)

4,814/50,445 (10%)

Practitioner Characteristics (%), by Region

Variable
Gender* Male Female NH White* Yes No Grad Year* Before 1984 1984 or later

AL/MS n=9
7 (78) 2 (22) 7 (78) 2 (22)

FL/GA n=19
15 (79) 4 (21) 15 (79) 4 (21)

MN n=13
8 (62) 5 (38) 13 (100) 0 (0)

PDA n=15
10 (67) 5 (33) 8 (53) 7 (47)

SK n=25
6 (24) 19 (76) 25 (100) 0 (0)

TOTAL n=81
46 (57) 35 (43) 68 (84) 13 (16)

5 (55) 4 (44)

10 (56) 8 (44)

8 (62) 5 (38)

1 (7) 14 (93)

10 (40) 15 (60)

34 (42) 46 (58)

*p<0.05

Patient Characteristics (%), by Region

Variable AL/MS n=296 FL/GA n=475 MN n=296 PDA n=106 SK n=592 TOTAL n=1,765

Gender* Male Female Race/Ethnicity* NH White NH Black Hispanic Other (AI/Asian/AN/PI) Age* 18 years or younger 19-44 years old 45-64 years old 65 and older Dental Insurance* Yes No

121 (41) 175 (59) 212 (72) 71 (24) 4 (1) 9 (3)

238 (50) 237 (50) 297 (62) 84 (18) 69 (15) 25 (5)

127 (43) 168 (59) 204 (69) 35 (12) 16 (5) 41 (14)

43 (41) 63 (59) 85 (80) 5 (5) 4 (4) 4 (4)

301 (51) 289 (49) 530 (90) 2 (0) 8 (1) 52 (9)

830 (47) 932 (53) 1,328 (75) 197 (11) 101 (6) 139 (8)

129 (44) 89 (30) 68 (23) 10 (3)

98 (21) 217 (46) 129 (27) 30 (6)

74 (25) 134 (45) 78 (26) 10 (3)

35 (33) 53 (50) 15 (14) 3 (3)

143 (24) 320 (54) 103 (18) 26 (4)

479 (27) 813 (46) 393 (22) 79 (5)

262 (89) 34 (11)

356 (75) 119 (25)

269 (91) 27 (9)

102 (96) 4 (44)

592 (100) 0 (0)

1,581 (90) 184 (10)

*p<0.05 patients who were enrolled in the study

Conclusions

To our knowledge, this is the first study to quantify the prevalence of QOC in routine clinical practice. These results document wide variations in prevalence among DPBRNs five main regions. If there is strong evidence regarding the frequency and progression of QOC, non-invasive management strategies may be more widely accepted, thereby conserving tooth structure.

DPBRN Studies
In the past, have focused on collecting information on normal routine practice Goal is to perform RCT One main area of interest is when to place the first restoration on a tooth and if sealants really work. Can caries really become inactive when sealed? Purpose of PROSOC_DPBRN

PROSOC_DPBRN
Permanent Restoration or Sealing Occlusal Caries Study objectives: (1) To test the hypothesis that sealing caries non-surgically is equivalent to surgical intervention with a permanent composite restoration for tooth-level outcomes observed during two years of follow-up; and (2) to test the hypothesis that sealing caries non-surgically is equivalent to surgical intervention with a permanent composite restoration for patient symptoms (sensitivity to temperature, spontaneous pain, pain to biting) during two years of follow-up. Regarding hypothesis 1, these tooth-level outcomes will be measured during the study: (1) whether the sealant or restoration remains intact after baseline (that is, whether it is lost or fractured); (2) whether the practitioner-investigator decides after baseline that the sealant or restoration needs to be repaired or replaced; (3) all treatment procedures, treatment visits, and the reason(s) for them that are done on the enrolled tooth after baseline; (4) whether there is any change in the radiographic appearance of the lesion or tooth after baseline. Regarding hypothesis 2, these patient-level outcomes will be measured at the 1-year and 2-year points in the study: (1) symptoms reported by the patient specific to the enrolled tooth, such as spontaneous pain or dental sensitivity to hot, cold, or sweets; (2) any other pain from the enrolled tooth or quadrant. Certain characteristics of the patient (e.g., socio-demographic characteristics, use of fluoridated products, and residence in an area with a fluoridated water supply) and the tooth (tooth number, presence of other restorations on the tooth, characteristics of the opposing occlusion and adjacent teeth) will be recorded at baseline because risk assessment is a vital part of the clinical decision-making process1.

Why a Study on Sealants?

Reduction of caries seen more in smooth surfaces and proximal lesions Increase in pits and fissures (80% of all lesions begin in the pits and fissures) The importance of sealants

Patient presents to the practice with eligible lesion: patient is at least 6 years of age; presents with an permanent posterior tooth with an occlusal caries lesion that is limited to the enamel; has a recent bitewing (within the last 12 months); is available for 2 years of follow-up; is a regular attender for the past 2 years; and is able to provide informed consent

After informed consent is obtained, the practitioner opens sealed envelope which dictates to which of the two arms the patient has been assigned:

SEALANT ARM: With or without air abrasion, place sealant according to manufacturer specifications

OPERATIVE TREATMENT ARM: Remove all caries and place composite material according to manufacturer specifications

After placement of the sealant or composite, practitioner fills out data collection form which asks questions regarding the clinical characteristics of this lesion, any patient symptoms, as well as patient and tooth characteristics.

Patient returns for routine care. At the 12- and 24-month intervals, the practitioner takes a bitewing radiograph of the tooth and completes the data collection form which asks questions regarding the clinical and radiographic characteristics of the lesions as well as any patient symptoms. If the patient returns prior to the allotted intervals for that tooth, the practitioner will complete the data collection form at that time. If the
practitioner diagnoses decay and/or feels the need to place a permanent restoration (if the patient was assigned to the Sealant Arm), then he/she may do so at this time.

Detecting caries with probe instead of explorer-less chance of breaking possible remineralization

Past studies on sealants.. are they really beneficial?

Mertz-Fairhurst, et al. Ultraconservative and cariostatic sealed restorations: Results at year 10 Sealants over carious lesions vs Caries removed and amalgam with sealant vs Caries removed and amalgam

Patient criteria: Must have at least 2 class I lesions with radiographic and clinically visible caries No deeper than way into dentin For amalgam restoration group: removed all caries in addition to noncarious fissures For conservative amalgam with sealant group: removed all caries, but not extended into noncarious parts. Sealant was then placed over everything For sealant group: for each patient, one of the above was paired with this sealant group. Sealant placed directly over caries. The only prep involved a 45-60 degree bevel in the enamel

Four Celled Study Design

Group 1 Teeth with bonded and sealed composite restoration over caries (n=77) Group 3 Teeth with sealed amalgam restoration (n=77)

Group 2 Teeth with bonded and sealed composite restoration over caries (n=79) Group 4 Teeth with unsealed amalgam restorations (n=79)

Occurrence of Clinical Failures of Restorations Through Year 10 Time Number of Failures

Sealant over caries Sealed amalgam (n=156 at baseline) (n=77 at baseline) 6 months-2 yrs 3 yrs 4 yrs 5 yrs 6 yrs 9 yrs 10 yrs Cumulative failures 1 3 + 1(unrelated) 4 1 0 +1 (unrelated) 3 +2 (unrelated) 0 12 + 4 (unrelated) (14%) (n=85) 0 + 1 (unrelated) 0 1 0 0 0 0 1 +1 (unrelated) (2%) (n=44) Unsealed amalgam (n=79 at baseline) 0 0 2 1 1 2 1 7 (17%) (n=41)

Survival Analysis using Wilcoxons test at year 10

Comparison Group
77 bonded and sealed carious restorations vs 79 bonded and sealed carious restorations 77 sealed carious restorations vs 77 sealed amalgam restorations 79 bonded and sealed carious restorations vs 79 unsealed amalgam restorations 77 sealed amalgam vs 79 unsealed amalgam

P-Value
0.8990 (not significant)

0.0322 (significant; sealed amalgam is superior) 0.8320 (not significant)

0.242 (significant difference; sealed amalgam is superior)

The use of a pit and fissure sealant around amalgam margins was the most successful

Sealant group: not all caries removed; bevel placed

After sealant placed

Year 10

Sealant placed; baseline Year 6

Year 10

Radiographic image of same teeth. Caries into dentin

After sealants placed. Caries still visible. Year 6

Year 10. Caries still at same levels. Has not progressed

Conclusions
With proper seal, it is possible to arrest frank cavitated lesions, even after 10 years. The sealed amalgam had the best survival rates

PROSOC_DPBRN will be different in that we will compare sealant vs composite, in which 64% of our dentists use over amalgam. Amalgam is banned in Sweden and Denmark due to environmental and health concerns