468 JADA 144(5) http://jada.ada.org May 2013

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tal treatment.7 However, the determination of the “clinical significance” of CACs does not fall within the scope of dental practice in most, if any, states. Dentists should show these le-sions to their patients and then develop a written consultation directed to either the patient’s primary care physician or an-other knowledgeable medical specialist.

Arthur H. Friedlander, DMD

Professor-in-ResidenceOral and Maxillofacial Surgery

UCLA Dental Schooland

Director of Quality AssuranceHospital Dental Service

UCLA Medical Centerand

Associate Chief of Staff/Director Graduate Medical Education

VA Greater Los Angeles Healthcare System

1. Pette GA, Norkin FJ, Ganeles J, et al. Incidental findings from a retrospective study of 318 cone beam computed tomogra-phy consultation reports. Int J Oral Maxil-lofac Implants 2012;27(3):595-603.

2. Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospec-tive study (published online ahead of print Sept. 30, 2011). Clin Oral Implants Res 2011;23(11):1261-1268. doi:10.1111/j.1600-0501.2011.02299.x.

3. Nandalur KR, Baskurt E, Hagspiel KD, et al. Carotid artery calcification on CT may independently predict stroke risk. AJR Am J Roentgenol 2006;186(2):547-552.

4. Bos D, Ikram A, Elias-Smale SE, et al. Calcification in major vessel beds relates to vascular brain disease (published online ahead of print Aug. 25, 2011). Arterioscler Throm Vasc Biol 2011;31(10):2331-2337. doi:10.1161/ATVBAHA.111.232728.

5. Prabhakaran S, Singh R, Zhou X, Ramas R, Sacco RL, Rundek T. Presence of calcified carotid plaque predicts vascular events: the Northern Manhattan Study (published online ahead of print May 4, 2007). Atherosclerosis 2007;195(1):e197-e201. doi:10.1016/j.atherosclerosis.2007.03.044.

6. Ciccone MM, Marzullo A, Mizio D, et al. Can carotid plaque histology selectively predict risk of acute coronary syndrome? Int Heart J 2011;52(2):72-77.

7. Grimes RM, Richards E, Flaitz CM. Avoiding malpractice for nondental condi-tions: the example of human immunodefi-ciency virus. JADA 2011;132(4):499-507.

Authors’ response: We thank Dr. Friedlander for his comments and concerns

regarding our article. In re-sponse, it appears clear, based on the provided published literature,1-5 that carotid ar-tery calcifications (CACs) do serve as a predictor for future vascular events. However, it needs to be noted that the cited studies investigated different imaging techniques (ultra-sound, multidetector computed tomographyangiography, etc.), results that cannot be directly extrapolated to cone-beam computed tomography (CBCT) imaging without some valida-tion studies.

Hopefully, CBCT imaging will be shown in the future to be diagnostically accurate for CACs. Our intention in that paragraph was to recognize that the diagnostic validity and, by association, clinical significance of most of the inci-dental findings (IFs) has yet to be thoroughly evaluated spe-cifically using CBCT. We did not intend to imply that CACs were nonsignificant in general. Rather, in this paragraph on page 167, we state that CACs were considered clinically sig-nificant in the articles in which they were detected:

Although it is difficult to know with certainty which IFs are truly of clinical significance, clinical significance was mentioned in two of five studies.[4,5] From these two articles, common IFs labeled as clinically significant were endodontic lesions (10.8-32.7 per-cent), carotid artery calcifications (4.3 percent) and dentigerous cysts (2.6 percent). … The effect of clinically significant IFs on patient care is difficult to assess, although at minimum it may be important to record them.

Furthermore, the emphasis of the systematic review (SR) was to provide the clinician with information regarding the frequency in which occult find-ings or pathologies in general are identified in the maxillofa-cial region. It was not our in-

tention to be specific in regards to any singular IF or to provide guidelines on how to manage these findings.

We agree with Dr. Fried-lander’s statement regarding our professional responsibility to diagnose maxillofacial con-ditions that are indicators of systemic disease. But the real-ity is, as mentioned in our SR, that it is still unclear exactly how the dental practitioner is expected to manage these find-ings. Perhaps we should have included further discussion and suggestions that clinicians should discuss these findings with their patients and make the appropriate referral to the patient’s primary care physician.

The SR message was more importantly geared around the discussion of whether the dental practitioner actually is trained properly to inter-pret CBCT images and, if so, whether each clinician is prop-erly and thoroughly interpret-ing each image.

Ryan Edwards, DDSStudent

Mostafa Altalibi, DMDStudent

Orthodontic Graduate Program

Carlos Flores-Mir, DDS, DSc

Associate Professor and Head

Division of Orthodontics Department of Dentistry

Faculty of Medicine and Dentistry

University of AlbertaEdmonton

Canada

1. Caglayan F, Tozoglu U. Incidental findings in maxillofacial region detected by cone beam CT (published online ahead of print Sept. 29, 2011). Diagn Interv Radiol 2012;18(2):159-163. doi:10.4261/1305-3825.DIR.4341-11.2.

2. Cha J, Mah J, Sinclair P. Incidental findings in the maxillofacial area with 3- dimensional cone-beam imaging. Am J Or-thod Dentofacial Orthop 2007;132(1):7-14.

3. Pette GA, Norkin FJ, Ganeles J, et al.

C O M M E N T A R Y L E T T E R S

Copyright © 2013 American Dental Association. All Rights Reserved.

470 JADA 144(5) http://jada.ada.org May 2013

Incidental findings from a retrospective study of 318 cone beam computed tomogra-phy consultation reports. Int J Oral Maxil-lofac Implants 2012;27(3):595-603.

4. Pliska B, DeRocher M, Larson BE. Incidence of significant findings on CBCT scans of an orthodontic patient population. Northwest Dent 2011;90(2):12-16.

5. Price JB, Thaw KL, Tyndall DA, Ludlow JB, Padilla RJ. Incidental findings from cone beam computed tomography of the maxillofacial region: a descriptive retrospec-tive study (published online ahead of print Sept. 30, 2011). Clin Oral Implants Res 2011;23(11):1261-1268. doi:10.1111/j.1600-0501.2011.02299.x.

XYLITOL FOR ADULT CARIES I am writing regarding Dr. James Bader and colleagues’ January JADA article, “Results From the Xylitol for Adult Car-ies Trial (X-ACT)” (Bader JD, Vollmer WM, Shugars DA, et al. JADA 2013;144[1]:21-30).

It is difficult to understand why this elaborate study was undertaken given the paucity of objective evidence—clinical, animal or laboratory-based—to support the contention that xylitol has a therapeutic ef-fect; that is, that it prevents dental caries. Indeed, several reviewers have pointed out the sparseness of evidence. For example, one reviewer wrote, “There is no evidence for a minimal therapeutic dose or a caries-therapeutic effect of xylitol.”1 This observation is consistent with prior indepen-dent reviews.2,3 Certainly, data reveal that xylitol is noncariogenic.4

Unsurprisingly, results from the present study are hardly supportive of any therapeutic effect arising from the inges-tion of xylitol. However, the present study is not without a potential flaw. Sucralose was used to sweeten the control because it “lacks any plausible biological cariostatic or car-iogenic properties other than sugar substitution.”

The basis for this statement is unclear. Sucralose is an in-hibitor of glucosyltransferases; these enzymes are virulence

properties of Streptococcus mutans, involved in the forma-tion of the matrix of dental plaque.5,6 Although the anti-cariogenic property of sucra-lose has not been determined, clearly it can hardly be dis-missed and, certainly, cannot at this stage be regarded as an inactive control. Care should be exercised to ensure in trials such as this that controls are truly inactive.

William H. Bowen, BDS, PhD

Professor EmeritusMicrobiology and Immunology

Center for Oral BiologySchool of Medicine and Dentistry

University of RochesterN.Y.

1. Van Loveren C. Sugar alcohols: what is the evidence for caries-preventive and caries-therapeutic effects? Caries Res 2004; 38(3):286-293.

2. Scheie AA, Fejerskov OB. Xylitol in caries prevention: what is the evidence for clinical efficacy? Oral Dis 1998;4(4):268-278.

3. European Commission Health & Consumer Protection Directorate-General. Opinion on Revision of the Scientific Opinion on the Effects of Xylitol and Other Polyols on Caries Development Adopted by the Scientific Committee on Medicinal Products and Medical Devices on 2 June 1999: Adopted by the Scientific Committee on Medicinal Products and Medical Devices on 26 September 2002. http://ec.europa.eu/health/archive/ph_risk/committees/scmp/documents/out44_en.pdf. Accessed March 14, 2013.

4. Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar studies, V: final report on the effect of sucrose, fructose and xylitol diets on caries incidence in man. Acta Odontol Scand 1976;34(4):179-216.

5. Wunder D, Bowen WH. Action of agents on glucosyltransferases from Streptococ-cus mutans in solution and adsorbed to experimental pellicle. Archives Oral Biol 1999;44(3):203-214.

6. Bowen WH, Koo H. Biology of Strep-tococcus mutans-derived glucosyltransfer-ases: role in extracellular matrix formation of cariogenic biofilms (published online ahead of print Feb. 23, 2011). Caries Res 2011;45(1):69-86. doi:10.1159/000324598.

Author’s response: Dr. Bowen cites two traditional literature reviews,1,2 one of which we also cited in our re-port,1 noting the lack of strong evidence for the effectiveness of xylitol for the prevention of dental caries. However, what Dr. Bowen fails to cite is a

larger body of systematic and traditional reviews that either conclude that xylitol is effec-tive,3-5 or find the evidence to be inconclusive6,7 and call for randomized controlled trials to resolve the question.

This disagreement in re-viewers’ conclusions is pre-cisely why we conducted our trial; to try to resolve the con-troversy concerning xylitol’s effectiveness. All of the reviews cited indicated the need for additional evidence, and the need for this evidence is under-scored by the recommendation that public health programs consider using xylitol in caries preventive programs.8

As Dr. Bowen notes, the anticariogenic properties of sucralose have not been de-termined, and it has not been associated clinically with any cariostatic or anitcariogenic ef-fects. Furthermore, our analy-ses showed no discernible dose-response effect associated with the use of the control group lozenges, which were sweet-ened with sucralose. James D. Bader, DDS, MPH

Research Professor Department of Operative

DentistrySchool of Dentistry

University of North Carolina at Chapel Hill

and Associate Editor

for Evidence-Based Dentistryfor The Journal of the American

Dental Association

1. Van Loveren C. Sugar alcohols: what is the evidence for caries preventive and caries-therapeutic effects? Caries Res 2004; 38(3):286-293.

2. Scheie AA, Fejerskov OB. Xylitol in caries prevention: what is the evidence for clinical efficacy? Oral Dis 1998;4(4):268-278.

3. Hayes C. The effect of non-cariogenic sweeteners on the prevention of dental car-ies: a review of the evidence. J Dent Educ 2001;65(10):1106-1109.

4. Maguire A, Rugg-Gunn AJ. Xylitol and caries prevention--is it a magic bullet? Br Dent J 2003;194(8):429-436.

5. Deshpande A, Jadad AR. The impact of polyol-containing chewing gums on dental caries: a systematic review of original ran-domized controlled trials and observational

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Copyright © 2013 American Dental Association. All Rights Reserved.