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This systematic review evaluates evidence describing histologically validated performance of methods for identifying carious lesions. A search identified 1,407 articles, of which 39 were included that described 126 assessment of visual, visual/tactile, radiographic (film and digital), fiber optic transillumination, electrical conductance, and laser fluorescence methods. A subsequent update added four studies contributing 10 assessments. The strength of the evidence was judged to be poor for all applications, signifying that the available information is insufficient to support generalizable estimates of the sensitivity and specificity of any given application of a diagnostic method. The literature is problematic with respect to complete reporting of methods, variations in histological validation methods, the small number of in vivo studies, selection of teeth, small numbers of examiners, and other factors threatening both internal and external validity. Future research must address these problems as well as expand the range of assessments to include primary teeth and root surfaces.

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A systematic review of the periodic scientific literature was undertaken to determine the strength of the evidence for the efficacy of professional caries preventive methods applied to high risk individuals, and the efficacy of professionally applied methods to arrest or reverse non-cavitated carious lesions. An initial search identified 1435 articles, of which 27 were eventually included in the review. Among the 22 studies addressing the prevention of carious lesions in caries-active or high risk individuals, the strength of the evidence was judged to be fair for fluoride varnishes and insufficient for all other methods. Among the seven studies addressing the management of non-cavitated carious lesions, the strength of the evidence for efficacy was judged to be insufficient for all methods. The results do not indicate that the preventive and management methods reviewed are not efficacious; rather, they demonstrate that not enough is known to determine the efficacy of the methods. Suggestions for strengthening the limited evidence base involve the following: i) increasing the number of studies that examine prevention among high risk individuals and non-surgical management of non-cavitated lesions, ii) including a wider variety of subject ages, iii) targeting aspects of the efficacy questions not yet addressed, iv) strengthening research methods employed in the studies, and v) reporting methods and outcomes more completely.

A systematic review of the English-language literature was conducted to address three related questions concerning the diagnosis and management of dental caries: a) the performance (sensitivity, specificity) of currently available diagnostic methods for carious lesions, b) the efficacy of approaches to the management of noncavitated or initial carious lesions, and c) the efficacy of preventive methods among individuals who have experienced or are expected to experience elevated incidence of carious lesions. From 1,328 caries diagnostic and 1,435 caries management reports originally identified, thirty-nine diagnostic studies and twenty-seven management studies were included in the final evidence tables. Point estimates or reasonable range estimates for the diagnostic validity of methods for the diagnosis of carious lesions could not be established from the literature reviewed.There are insufficient numbers of reports of diagnostic performance involving primary teeth, anterior teeth, and root surfaces. For posterior occlusal and proximal surfaces, quality issues and the variation among studies precludes establishing such estimates. The apparent differences in sensitivity among methods are generally smaller than the variation reported within methods. The literature on the management of noncavitated carious lesions consisted of five studies describing seven experimental interventions. Because these interventions varied extensively in terms of management methods tested as well as other study characteristics, no conclusions about the efficacy of these methods were possible. The literature on the management of individuals at elevated risk of carious lesions consisted of twenty-two studies describing twenty-nine experimental interventions. The strength of the evidence for the efficacy of fluoride varnish for prevention of dental caries in high-risk subjects was fair, and the evidence for all other methods was incomplete. Because the evidence for efficacy for some methods, including chlorhexidine, sucrose-free gum, and combined chlorhexidine-fluoride methods, is suggestive but not conclusive, these interventions represent fruitful areas for further research.

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A conceptual model of dentists' treatment decision-making is discussed. The model suggests that dentists do not use a hypothetico-deductive process for the diagnosis of caries. Rather, caries is identified through a process of pattern recognition that in most instances is inextricably linked to intervention decisions. Individual dentists have inventories of caries scripts that, when matched by a particular clinical presentation, lead to decisions to treat. The scripts comprise salient factors that are dependent on individual dentist's characteristics and biases, and thus vary substantially across dentists. The scripts tend to be complex, highly visual, and difficult to describe. All of these characteristics suggest that efforts to improve dentists' caries-related treatment decisions should acknowledge this knowledge structure and be designed to change the salient factors or interpretations of salient factors within the context of the caries script.

Objective-To identify risk indicators that are associated with root caries incidence in published predictive risk models.Methods-Abstracts (n=472) identified from a MEDLINE, EMBASE, and Cochrane registry search were screened independently by two investigators to exclude articles not in English (n=39), published prior to 1970 (none), or containing no information on either root caries incidence, risk indicators, or risk models (n=209). A full-article duplicate review of the remaining articles (n=224) selected those reporting predictive risk models based on original/primary longitudinal root caries incidence studies. The quality of the included articles was assessed based both on selected criteria of methodological standards for observational studies and on the statistical quality of the modeling strategy. Data from these included studies were extracted and compiled into evidence tables, which included information about the cohort location, incidence period, sample size, age of the study participants, risk indicators included in the model, root caries incidence, modeling strategy, significant risk indicators/predictors, and parameter estimates and statistical findings.Results-Thirteen articles were selected for data extraction. The overall quality of the included articles was poor to moderate. Root caries incidence ranged fro m 12%-77% (mean±SD=45% ±17%); follow-up time of the published studies was ≤10 years (range=9; median=3); sample size ranged from 23-723 (mean±SD=264±203; median=261); person-years ranged from 23-1540 (mean±SD=760±556; median=746). Variables most frequently tested and significantly associated with root caries incidence were (times tested; % significant; directionality): baseline root caries (12; 58%; positive); number of teeth (7; 71%; 3 times positive, twice negative), and plaque index (4; 100%; positive). Ninety-two other clinical and non-clinical variables were tested: 27 were tested 3 times or more and were significant between 9% and 100% of the times tested; and 65 were tested but never significant. Conclusions-The root caries incidence indicators/predictors most frequently reported were root caries prevalence at baseline, number of teeth, and plaque index. This finding can guide targeted root caries prevention. There was substantial variation among published models of root caries risk in terms of variable selection, sample size, cohort location, assessment methods, incidence periods, association directionality, and analytical techniques. Future studies should emphasize variables frequently tested and often significant, and validate existing models in independent databases.