R

ABSTRACT
Background. The purpose of this study was to quantify conservation of tooth structure and evaluate the efficacy of early treatment of questionable carious lesions in pits and fissures of posterior teeth using air abrasion followed by placement of preventive resin restorations. Methods. Ninety-three patients with 223 questionably carious teeth, mainly with darkly stained pits and fissures, were recruited from general dentistry clinics. After baseline evaluation, each tooth was randomly assigned to either an early treatment or control group. The authors used air abrasion to investigate the pits and fissures of teeth in the early treatment group. The teeth were sealed and restored with a flowable resin-based composite. All teeth in both groups were examined at six-month intervals to clinically evaluate the quality of the restorations and the caries status of the control teeth. Results. After two years, two of the 113 restorations in the early treatment group required further treatment because of penetrating stain at a margin. In the control group, 14 teeth required treatment because of caries. The mean weight of the impression materiala surrogate measure of volume of removed tooth structurein preparations that extended into dentin in the early treatment group was 0.0260 grams compared with 0.0281 g in the control group. There was no statistically significant difference between the impression weights (P = .390). Conclusion. After two years of a proposed five-year study, the authors concluded that conservation of tooth structure was not substantiated by early treatment. Clinical Implications. Treating questionable carious lesions early may not conserve tooth structure.

Early treatment of incipient carious lesions

A two-year clinical evaluation
JAMES C. HAMILTON, D.D.S.; JOSEPH B. DENNISON, D.D.S., M.S.; KENNETH W. STOFFERS, D.M.D., M.S.; WILLIAM A. GREGORY, D.D.S., M.S.; KATHLEEN B. WELCH, M.P.H., M.S.

any dental practitioners use dental air abrasion when treating small carious lesions.1,2 Air abrasion also has been recommended to aid in the diagnosis of questionable pit and fissure lesions.3-5 It would seem that the earlier a carious lesion is treated, the smaller the preparation is and the more tooth structure that can be conserved. The potential advantages of early treatment with air abrasion include the conservation of tooth structure, treatment of small carious lesions without the need for local anesthetic5-7 and the ability to create small preparations without the noise and vibration of a high-speed rotary handpiece. A disadvantage of early operative intervention is the elimination of the After two potential for small incipient lesions to years, tooth remineralize or arrest such that they do structure was not need operative intervention. Resinnot conserved based composites, which most often are as a result of used to restore air-abraded teeth, require the use of a bonding agent for early treatment optimal results.8,9 Currently used of questionable bonding agents and resin-based composcarious lesions ites are subject to technical considerain posterior tions such as moisture control, pooling teeth. of the low-viscosity agents and adequate light curing. This is problematic when treating posterior teeth in particular and can lead to a more technically challenging procedure. In addition, once restored, these teeth require continuing maintenance,10,11 because of possible wear, microleakage or fracture of the restorative material.

Given that there are advantages and disadvantages associated with the early treatment of small, questionable carious lesions, we initiated a randomized controlled clinical study to investigate the merits of early treatment of these lesions. Although the application of pit
1643

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

R E S E A R C H

and fissure sealants would be appropriate for teeth in all but the oldest patients in this study, we did not use sealants because the hypothesis to be investigated was the effect of early treatment of questionable carious lesions, not preventive measures to control the progression of these lesions. This report will review the two-year results of a proposed five-year study.
PATIENTS, MATERIALS AND METHODS

Before we recruited patients for this clinical study, the Institutional Review Board of the University of Michigan, Ann Arbor, examined and approved the protocol, as well as the consent and assent forms. The assent form, which is similar to a consent form, but written at a level to be understood by the youngest patients, was required to be signed by minors enrolled in the study. In addition, the consent form was signed by parents or guardians. New and returning patients between the ages of 12 and 36 years were recruited from patients who received a routine dental examination at the University of Michigan School of Dentistry and had at least one questionable carious lesion in any of the pits and fissures of a posterior tooth. We made no distinction between pits or fissures on the buccal or lingual surfaces of the tooth. The diagnosis of questionable was made by dentists who were supervising dental students, but who were not part of the clinical study. Patients were asked if they would be willing to participate in a clinical study to investigate the early treatment of very small carious lesions. If a patient indicated interest, he or she filled out a referral card that was given to the research coordinator (who was not a dentist) to schedule a baseline examination. We kept no records of patients who declined to participate. We defined questionable as no frank caries detected by conventional examination (that is, softness, decalcification or cavitation at the base of a pit or fissure, or evidence of radiolucency seen on bitewing radiographs, which were available for all patients), but we were uncertain about whether caries was present when deep staining or explorer retention was observed. The vast majority of these questionable lesions were darkly stained pits and fissures. We enrolled a maximum of three teeth from each patient to increase the variability of caries risk and to limit the number of teeth lost to follow-up if a patient missed a recall evaluation.
1644

Although not a requirement for selection, all enrolled teeth were in occlusion with natural dentition. Patients were excluded from the study if they had five or more active carious lesions, which is an indication of high caries risk or significant oral health neglect that could influence the rate of caries development independently of the pit or fissure defect. We also excluded patients with a physical or mental handicap that would limit oral hygiene practices or predispose them to an unusually high caries risk. Although these exclusion criteria were placed in the protocol to limit the risk to patients enrolled in the study, no patients with questionable carious lesions were excluded owing to these restrictions. Ninety-three patients with 223 questionable carious lesions were enrolled in the study. Each enrolled tooth was examined independently by two dentists who were selected from three of us (J.H., J.D., K.S.) based on our availability at the time of the baseline evaluations. We all used air from an air-water syringe, no. 13-14 explorers purchased and used only for this study, and 2.5 magnification to examine the study teeth. Each of the dentist examiners had a minimum of 25 years of clinical experience. Each dentist probed the pits and fissures of each study tooth extensively. Each dentist evaluated the darkest color of the pit and fissure system, explorer retention in a pit or fissure and gingival health using the Le and Silness Gingival Health Index.12 One examiner scored the amount of plaque on each study tooth using the Simplified Oral Hygiene Index.13 Box 1 shows the evaluation criteria. Either of the two examining dentists took 35-millimeter slides of the teeth at a magnification of 1.5. Impressions of the occlusal surface of the study teeth were fabricated using a clear polyvinyl siloxane bite registration material. To determine the history or prevalence of dental caries in each patient, we recorded a decayed, missing and filled surfaces, or DMFS, index, as defined by the World Health Organization,14 at baseline and yearly thereafter. This DMFS score for each patient was linked to each treatment or control tooth in that patient. The mean DMFS scores for the treatment and control groups were calculated by averaging the linked scores for each tooth in the two groups. Erupted third molars were included in the DMFS score for the few patients who had them. None of

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

R E S E A R C H

the teeth with questionable carious lesions were partially erupted. After all baseline measurements were completed, each tooth was randomly assigned to an early treatment group or the control group based on a table of random numbers.15 Patients with teeth assigned to the early treatment group were told that although local anesthetic usually was not necessary when treating small lesions with air abrasion, the operator would be willing to administer it at any time if the patient desired. With the patients concurrence, all air-abrasion procedures were initiated without the injection of local anesthetic. Air abrasion. After application of a rubber dam, the dentist air-abraded the questionable pits and fissures of the 113 teeth randomized into the early treatment group using 27-micrometer aluminum oxide powder starting at 80 pounds per square inch (5.8 kilograms per square centimeter). If the completed preparation extended into dentinan evaluation made independently by the two dentistsan impression was taken to measure the lost tooth structure. Using the impression of the occlusal surface taken during the baseline examination to form the occlusal surface of the preparation impression, the dentist injected a quick-setting polyvinyl siloxane lowviscosity impression material into the preparation. The impression was weighed as a surrogate measure of the amount of tooth structure lost. All teeth with preparations that extended into dentin and those with preparations that extended only into enamel were restored or sealed with a flowable light-cured resin-based composite (Tetric Flow, Ivoclar Vivadent Inc., Schaan, Liechtenstein). Every tooth in the treatment group received at least a prepared sealant (that is, for those preparations that were entirely within enamel). We believed that a lightly filled resin would be more appropriate for sealing these narrow enamel-only preparations. If the preparation extended into dentin, the dentist placed a preventive resin restoration with the radiating fissures sealed, using air abrasion and sealing with a flowable resin-based composite. This was done according to the manufacturers instructions (that is, etching with phosphoric acid gel for 20 seconds, rinsing with water for 15 seconds and applying two light-cured coats of bonding agent [Syntac SC, Ivoclar Vivadent Inc.]). Finishing and polishing were performed using slow-speed burs and rubber points. Recall examinations. Two of the four dentist

BOX 1

EVALUATION CRITERIA AT BASELINE AND RECALL EXAMINATIONS.*

GINGIVAL HEALTH A Normal B Marginal gingivitis C Chronic gingivitis PLAQUE INDEX 0 No plaque visible 1 Film of plaque visible only with periodontal probe 2 Moderate amount of soft deposits visible 3 Abundant amount of soft deposits visible A B C D E PIT AND FISSURE COLOR Tooth colored Yellow/orange Light brown Dark brown Black

PIT AND FISSURE FEEL A No stick B Slight stick C Resistance to removal CARIES Yes No ` Caries present Caries absent

* If a tooth is treated, the pit and fissure color and feel are replaced with the restorative evaluation criteria shown in Box 2. Source: Le and Silness.12 Source: Greene and Vermillion.13

authors re-examined the 113 treated teeth and 110 control teeth at six-month intervals. Although bitewing radiographs were obtained at yearly intervals as part of the patients continuing care at the University of Michigan, we did not find them to be effective in diagnosing the small occlusal carious lesions of interest in this study. This was most likely due to the limited size of the lesions and their varied location on the occlusal surface. At each recall examination, all study teeth were evaluated independently by two dentists for gingival health. The quality of the restorations was evaluated according to modified Ryge criteria,16 and the retention of sealants was assessed according to the following criteria: present, partially lost and completely lost (Box 2). The dentists evaluated control teeth for color of the pit and fissure system, explorer retention and caries using the same criteria as those used at baseline: softness at the base of a pit or fissure, decalcification associated with a pit or fissure, or radiographic signs of caries. If a control tooth was diagnosed as having caries, it was treated exactly the same as a tooth that had been randomized to the treatment group at baseline. All teeth were
1645

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

R E S E A R C H

BOX 2

control and treatment groups is shown in MODIFIED RYGE EVALUATION CRITERIA FOR THE EARLY Table 2. TREATMENT GROUP AND TREATED CONTROL TEETH.* Statistical analysis. At yearly interCOLOR MATCH vals, we used the 2 O Visually undetectable A Visually detectableno mismatch in color test to compare the B Mismatch in colorwithin acceptable range number of teeth with C Mismatch in coloroutside acceptable range carious lesions MARGINAL DISCOLORATION extending into dentin A No discoloration anywhere on the margin in the early treatment B1 Discoloration noted along marginless than 50 percent of exposed margin B2 Discoloration noted along margingreater than 50 percent of exposed margin group with the C Discoloration penetrating along margin number that were MARGINAL ADAPTATION diagnosed and treated A1 Restorative material is continuous with adjacent tooth structure in the control group. A2 Restorative material presents a one-way catch to an explorer We also used discrete B Visible evidence of crevice formation that an explorer will penetrate C Visible evidence of crevice formation with exposure of dentin or base time survival analysis with logistic regresANATOMICAL FORM sion,17 as implemented A Restoration contour is continuous with existing anatomical tooth form in SAS software B Restoration is undercontoured with respect to existing anatomical tooth form C Restoration is undercontoured with dentin or base exposed release 8.2 (SAS Institute, Cary, N.C.), to SURFACE SMOOTHNESS determine the perA Smooth as natural adjacent tooth structure B Surface not as smooth as natural tooth structure but not pitted centage of control C Surface not as smooth as natural tooth structure and pitted teeth becoming SEALANT PRESENT carious. A All pits and fissures are covered Logistic regression B Partial loss of sealant with some pits and fissures exposed with generalized estiC All pit and fissure sealant lost mating equations for clustered data was Source: Ryge and Snyder.16 * O: Oscar; A: Alfa; B: Bravo; C: Charlie. used to determine which baseline factors photographed at each recall examination. (that is, pit and fissure color, pit and fissure feel, The dental assistant or research coordinator baseline DMFS index, fluoride use history, age, sex and tooth type) were related to control teeth recorded the independent scores for each criteria that were subsequently diagnosed as having from the two dentists; if there was any disagreement, the dentists reviewed the written criteria occlusal caries, as well as to treated teeth that and reached a consensus. The evaluators agreed had caries extending into dentin. The weights of 84 percent of the time before any review or disthe preparation impressionsa surrogate measure of volumeof the early treated teeth and the cussion took place. (Agreement ranged from 65 control teeth subsequently diagnosed as having percent for evaluation of pit and fissure feel to 91 caries and treated were compared using a t test percent for evaluation of anatomical form and presence of sealant.) All dentist authors, in pairs for independent samples. A P value of less than of two, were evaluators. Drs. Hamilton and Den.05 was considered significant. nison prepared and placed all restorations, but RESULTS did not necessarily evaluate all restorations or preparations at recall appointments. Dentist evalThe dentists re-examined 89 control teeth at 24 uators used 2.5 magnification and an explorer to months or longer (because patients were treated evaluate caries into dentin and the elimination of at staggered times). Nine (10 percent) of the teeth carious tooth structure. were diagnosed and treated for caries after one Table 1 shows the distribution of the 223 conyear; five additional teeth (6 percent) were diagtrol and treated teeth among the 93 patients. The nosed and treated in the second year. We found distribution of molars and premolars between the no significant effect of time on caries occurrence
JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

1646

R E S E A R C H

TABLE 1 in the control group (P = .8470). This means DISTRIBUTION OF TEETH TREATED AT BASELINE AND that the probability of a CONTROL TEETH. questionable carious lesion in the control group being VARIABLE NUMBER OF TEETH TOTAL diagnosed with caries did All Control Two One One All not increase or decrease Teeth Control Control Control Treatment significantly during the Teeth and Tooth and Tooth and Teeth One One Two two years. The probability Treatment Treatment Treatment of caries developing in Tooth Tooth Teeth teeth in the control group 23 20 7 20 23 93 No. of after two years was 16.1 Patients percent (95 percent confi43 60 14 60 46 223 No. of dence interval, 9.3 percent Teeth to 26.3 percent). The number of control teeth TABLE 2 diagnosed with caries during the first two years of the study was significantly less than the number DISTRIBUTION OF TOOTH TYPE of teeth with caries that extended into dentin in BETWEEN TREATMENT AND the treatment group at baseline (P < .001). CONTROL GROUPS. The mean weight of the impression material in TOOTH TYPE NUMBER OF TEETH preparations that extended into dentin (a surrogate measure of tooth structure volume) in the Treatment Group Control Group early treatment group was 0.0260 grams, com1 3 Third Molar pared with 0.0281 g in the control group. This 54 48 Second Molar was not a statistically significant difference (P = .390). The only significant baseline predictor 41 41 First Molar of a control tooth being diagnosed with caries was 7 11 Second pit and fissure feel evaluated with an explorer Premolar (P = .0149). This means that the more retentive 10 7 First Premolar the explorer was in the pit or fissure, the more 113 110 TOTAL likely the control tooth would be diagnosed as having caries and treated during the next 24 months. Table 3 shows the results of clinical evaluaappropriate treatment for many of the questiontions of preventive resin restorations and sealants able carious lesions in this study, we did not use placed at baseline using modified Ryge criteria16 them because the hypothesis being investigated at six months, 12 months, 18 months and 24 was the advantage of early operative intervention months. During the second year of the study, no into questionable carious lesions in the pits and restorations required re-treatment compared with fissures of posterior teeth. two restorations needing re-treatment during the At baseline, we discovered that caries had profirst year of the study. Table 4 (page 1649) shows gressed into dentin in 50 (44 percent) of the 113 the results of the evaluations of gingival health teeth with questionable carious lesions randomand the plaque index for all teeth and pit and fisized into the early treatment group. After two sure color and pit and fissure feel of control teeth years, only 14 teeth randomized into the control at six months, 12 months, 18 months and 24 group were diagnosed with caries. The criteria we months. Figure 1 (page 1650) shows the 24-month used for diagnosing caries throughout the study appearance of a tooth in the early treatment was softness at the base of a pit or fissure, decalgroup. Figure 2 (page 1650) shows the 24-month cification associated with a pit or fissure, or appearance of a tooth in the control group. cavitation. Probed teeth. We probed control teeth extenDISCUSSION sively with an explorer. This leads to two conAlthough pit and fissure sealants would be an cerns: the possible transmission of cariogenic bac-

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

1647

R E S E A R C H

TABLE 3

obtain an estimate of the percentage of control CLINICAL EVALUATION RESULTS OF TEETH TREATED AT teeth with questionable carious lesions that would BASELINE.* progress to unquestionCATEGORY NO. (PERCENTAGE) OF TEETH able caries each year of the study. Although no Six Months 12 Months 18 Months 24 Months previous study examined Color Match only questionable carious 43 (86) 40 (91) 50 (89) Oscar 58 (98) lesions, the cariologists estimate was that 25 per7 (14) 4 (9) 6 (11) Alfa 1 (2) cent of the teeth would Marginal Discoloration become carious each year. 49 (98) 42 (95) 54 (98) Alfa 59 (100) Since 44 percent of the teeth randomized to the 0 2 (5) 0 Bravo 1 0 early treatment group 1 (2) 0 0 Bravo 2 0 had clinically demon0 0 2 (2) Charlie 0 strated caries that had progressed into dentin Marginal Adaptation when treated at baseline, 39 (78) 36 (82) 51 (91) Alfa 1 55 (93) we expected to find more 9 (18) 6 (14) 2 (4) Alfa 2 4 (7) than 25 percent of the control teeth exhibiting 2 (4) 2 (4) 3 (5) Bravo 0 caries during each of the 0 0 0 Charlie 0 first two years. Anatomical Form One possible explanation for the low number of 46 (92) 43 (98) 55 (98) Alfa 59 (100) control teeth exhibiting 4 (8) 1 (2) 1 (2) Bravo 0 caries each year is that Surface Smoothness the rate of progression of caries in this population 46 (92) 38 (86) 54 (96) Alfa 58 (98) is lower than expected. 4 (8) 5 (11) 1 (2) Bravo 1 (2) Other possible explana0 1 (2) 1 (2) Charlie 0 tions are that the caries had arrested or reminerSealant Present alization had occurred, 48 (96) 41 (93) 55 (98) Alfa 57 (97) although these possibili1 (2) 0 0 Bravo 1 (2) ties run counter to current thinking about pro1 (2) 3 (7) 1 (2) Charlie 1 (2) gression of pit and fissure * Because it was not possible to distinguish preventive resin restorations from prepared sealants, they are caries that has extended combined in the table. Based on criteria from Ryge and Snyder.16 into dentin. Current explanations may have to be reconsidered if the teria from one tooth to the next, and damage to caries rate in the control group remains low. decalcified enamel and increased demineralizaDMFS scores. Another possible explanation tion.18,19 If these events took place, we would for a lower-than-expected caries rate might be expect that a greater number of control teeth related to the caries experience or susceptibility would be diagnosed and treated for caries than of the enrolled subjects. One measure of dental would otherwise be the case. However, this did caries experience or prevalence is the number of not happen during the 24 months of this study. DMFS present. The DMFS score for enrolled Cariologists estimate. Before the study patients ranged from 0 to 58, with a mean of 8.42 began, we consulted with two cariologists to and a standard deviation of 7.47. Figure 3 (page
1648 JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

R E S E A R C H

1650) illustrates the disTABLE 4 tribution of DMFS scores and their association with CLINICAL EVALUATION RESULTS AT RECALL study teeth. It is interAPPOINTMENTS. esting to note that four CATEGORY NO. (PERCENTAGE) OF TEETH teeth in the study were in patients with a DMFS Six Months 12 Months 18 Months 24 Months score of 0, while one Gingival Health* patient (one tooth) had a (All Study Teeth) DMFS score of 58. Thus 90 (93) 76 (92) 98 (91) 112 (93) Normal the caries prevalence 7 (7) 7 (8) 10 (9) 8 (7) Marginal Gingivitis varied within the study. The mean DMFS Plaque Index (All Study Teeth) scores of the group treated at baseline and 53 (55) 40 (48) 60 (56) 65 (54) 0 the control group were 40 (41) 36 (43) 33 (31) 40 (33) 1 9.26 and 7.43, respec4 (4) 7 (8) 12 (11) 14 (12) 2 tively. This difference is not statistically signifi0 0 3 (3) 1 (1) 3 cant (P = .087). However, Pit and Fissure Color because the P value is (Control Teeth) approaching a commonly 0 0 0 3 (5) Tooth Color accepted level of signifi2 (4) 0 3 (6) 3 (5) Yellow/Orange cance (P < .05), this issue deserves further 18 (38) 16 (41) 17 (33) 18 (29) Light Brown investigation. 27 (57) 22 (56) 31 (60) 38 (60) Dark Brown As noted in the 1220 0 1 (3) 1 (2) 1 (2) Black month results, demographic and baseline Pit and Fissure Feel (Control Teeth) evaluation variables associated with teeth in the 21 (45) 21 (54) 22 (42) 38 (62) No Stick early treatment group 17 (36) 13 (33) 20 (39) 15 (25) Slight Stick were analyzed using 9 (19) 5 (13) 10 (19) 8 (13) Resistance to logistic regressions with Removal generalizing equations. * Source: Le and Silness.12 DMFS was not signifi 0: No plaque visible; 1: film of plaque visible only with periodontal probe; 2: moderate amount of soft cantly related to caries deposits visible; 3: abundant amount of soft deposits visible. Source: Greene and Vermillion.13 extending into dentin in the early treatment group, but was borderline (P = .056). The surfact is, however, that despite the lower mean prising fact is that the higher the DMFS score DMFS score in the control group and our use of was at baseline, the less likely that caries had aggressive probing, the caries rate was still lower extended into dentin in teeth randomized into the than expected in the control group. treatment group. One possible explanation is that When comparing the size of the preparations in the most susceptible surfaces had already been the early treatment and control groups, we found restored, leaving only those surfaces that were it surprising how small these preparations were more resistant to caries. and how small the difference was between the In addition, this could be construed as the two groups. (The mean weights of the impressions lower ones DMFS score, the more likely that from the two groups differed by only 0.0021 g, or caries had extended into dentin and that the con1.6 cubic millimeters in size.) trol group, which had a lower overall DMFS, Darkly stained pits and fissures often have would have more caries into dentin than the early been associated with caries. In this study, these treatment group, which had a higher DMFS. The pits and fissures were divided into five categories
JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved. 1649

R E S E A R C H

30 NUMBER OF STUDY TEETH

20

10

0 1 2

3 4 5 6 7

8 9 10 11 12 13 14 15 16 21 22 24 27 58

DMFS SCORES
Figure 3. Caries prevalence as indicated by decayed, missing and filled surfaces, or DMFS, scores of patients associated with study teeth.

Figure 1. Preventive resin restoration in the mandibular first molar at 24-month recall examination.

Figure 2. Control tooth (mandibular second molar) at 24month recall examination.

ranging from tooth colored (nearly white) to black. This color range can be considered a continuous scale, and it was clear to the evaluators that in certain cases, there would be difficulty distinguishing a difference in adjacent categories, such as between tooth color and light yellow, between light brown and dark brown, and
1650

between dark brown and black. Consequently, the level of agreement (84 percent) between the evaluators was not unexpected. When we reduced the color scale to two categories (no stain [tooth color and yellow/orange] and stained [light brown, dark brown and black]), the agreement between evaluators was an acceptable 88 percent. Use of dental explorer. Using a dental explorer to probe the pits and fissures of teeth has often been an aid in diagnosing carious lesions21; however, many cariologists do not recommend the use of aggressive probing.18,19 Although specific explorers were purchased and used in this clinical study, we found differences between similar explorers. We also noted that the explorers were used with different pressures by different examiners. In retrospect, we should have developed pressure criteria. Moreover, it was clear to all examiners that physical changes to the pits and fissures occurred as a result of probing that made calibration impossible. In many cases, the pit or fissure became less retentive the more the tooth was probed. Given these problems, it is interesting to note that we found a strong relationship between pit and fissure feel and caries penetrating into dentin (P = .0149). The greater the retention of the explorer at the baseline examination, the more likely the control tooth would be diagnosed and treated for caries during the next 24 months. Although patients were excluded from the study if they had five or more active carious lesions, only one patient had an extensively cavitated lesion on enrollment. In retrospect, this

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

R E S E A R C H

Dr. Hamilton is a clinical associate professor, Department of Cariology, Restorative Sciences and Endodontics, the University of Michigan School of Dentistry, 1011 N. University, Ann Arbor, Mich. 48109-1078, e-mail jchamilt@ umich.edu. Address reprint requests to Dr. Hamilton.

Dr. Dennison is a professor, Department of Cariology, Restorative Sciences and Endodontics, the University of Michigan School of Dentistry, Ann Arbor.

Dr. Stoffers is an assistant professor, Department of Cariology, Restorative Sciences and Endodontics, the University of Michigan School of Dentistry, Ann Arbor.

Dr. Gregory is an adjunct professor of dentistry, Department of Cariology, Restorative Sciences and Endodontics, the University of Michigan School of Dentistry, Ann Arbor.

years, tooth structure was not conserved as a result of early treatment of questionable carious lesions in posterior teeth. The degree of explorer retention at baseline was significantly associated with caries being diagnosed later in control teeth. The preventive resin restorations and sealants placed in the early treatment group were performing well after two years. s

might have been expected, because if a patient has many grossly carious teeth, it could indicate a high caries rate. We would expect that teeth with questionable carious lesions would not stay questionable for long in a patient with a high caries rate. Caries-detecting dyes. Before this study began, we decided not to use any caries-detecting dye to aid in locating or removing carious dentin. This decision was based on two factors: dA review of the published literature indicated diverse opinions regarding the effectiveness of caries-detecting dyes. dWe wanted to use procedures that were commonly practiced by general dentists. In a review article on the efficacy of cariesdetecting dyes, McComb22 noted that with proper dental care, they were not necessary. None of the patients requested local anesthetic during treatment of the five control teeth in the second year of the study, compared with one patient in the first year. No patient reported any preoperative or postoperative sensitivity associated with any study tooth. Both of these findings suggest that the questionable carious lesions in the control group are not progressing quickly. This study did not measure the amount of tooth structure lost as a result of early treatment of the 63 teeth in which the questionable carious lesions were limited to enamel. We also did not predict the costs related to the lifetime maintenance these prepared sealants require. The lost tooth structure and lifetime maintenance costs need to be weighed against the benefits of treating caries at an early stage.
CONCLUSION

Ms. Welch is a statistical consultant, Center for Statistical Consultation and Research, The University of Michigan, Ann Arbor. This investigation was partially supported by Delta Dental Fund of Michigan. 1. Reis-Schmidt T. Air-abrasion cavity-preparation systems provide cutting-edge options in restorative dentistry. Dent Prod Rep 1998;32(12):57-60, 108-9. 2. White E. Established technology sparking new interest among first-time buyers of office equipment. Dent Prod Rep 1999;33(12):90-5. 3. Kotlow LA. New technology in pediatric dentistry. N Y State Dent J 1996;62(2):26-30. 4. Goldstein RE, Parkins FM. Using air-abrasive technology to diagnose and restore pit and fissure caries. JADA 1995;126(6):761-76. 5. Christensen GJ. Initial carious lesions: when should they be restored? JADA 2000;131:1760-2. 6. Berry EA 3rd, Eakle WS, Summitt JB. Air abrasion: an old technology reborn. Compend Contin Educ Dent 1999;20:751-9. 7. Morrison A, Berman L. Evaluation of the Airdent unit: preliminary report. JADA 1953;46(3):298-303. 8. Berry EA 3rd, Ward M. Bond strength of resin composite to airabraded enamel. Quintessence Int 1995;26:559-62. 9. Roeder LB, Berry EA 3rd, You C, Powers JM. Bond strength of composite to air-abraded enamel and dentin. Oper Dent 1995;20(5):186-90. 10. Wendt LK, Koch G, Birkhed D. Replacements of restorations in the primary and young permanent dentition. Swed Dent J 1998;22(4):149-55. 11. Hickel R, Manhart J. Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent 2001;3(1):45-64. 12. Le H, Silness J. Periodontal disease in pregnancy. Acta Odont Scand 1963;21:533-49. 13. Greene JC, Vermillion JR. The simplified oral hygiene index. JADA 1964;68:7-13. 14. World Health Organization. Oral health surveys: Basic methods. 3rd ed. Geneva: World Health Organization; 1997:35-8. 15. Meinert CL. Clinical trial design, conduct, and analysis. Oxford, England: Oxford University Press; 1986:96. 16. Ryge G, Snyder M. Evaluating the clinical quality of restorations. JADA 1973;87:369-77. 17. Allison PD. Survival analysis using the SAS system: A practical guide. Cary, N.C.: SAS Institute; 1995:211-32. 18. Ekstrand K, Qvist V, Thylstrup A. Light microscope study of the effect of probing in occlusal surfaces. Caries Res 1987;21:368-74. 19. Yassin OM. In vitro studies of the effect of a dental explorer on the formation of an artificial carious lesion. ASDC J Dent Child 1995;62(2):111-7. 20. Hamilton JC, Dennison JB, Stoffers KW, Welch KB. A clinical evaluation of air-abrasion treatment of questionable carious lesions: a 12-month report. JADA 2001;132:762-9. 21. Gilmore WH, Lund MR. Operative dentistry. 2nd ed. St. Louis: Mosby; 1973:34. 22. McComb D. Caries-detector dyes: how accurate and useful are they? J Can Dent Assoc 2000;66(4):195-8.

The results of this study show that after two

JADA, Vol. 133, December 2002 Copyright 2002 American Dental Association. All rights reserved.

1651