Fissure Caries Inhibition Study With Solea CO2-9.3μm Short-pulsed Laser - A Randomized, Single Blind, Prospective, Split Mouth Controlled, Clinical Trial
Phase: NA
Conditions: Dental Caries
Sponsor: University of California, San Francisco

Fissure Caries Inhibition Study Solea CO2-9.3μm short-pulsed laser 
 
Peter Rechmann and John D.B. Featherstone  
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Fissure Caries Inhibition Study with Solea CO2-9.3μm Short-pulsed 
Laser 
 
Peter Rechmann and John D.B. Featherstone 
 
NCT02357979 
 
Study Protocol and Statistical Analysis Plan 
 
 
 

Fissure Caries Inhibition Study Solea CO2-9.3μm short-pulsed laser 
 
Peter Rechmann and John D.B. Featherstone  
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1. 
TITLE PAGE 
Study Title: 
Fissure Caries Inhibition Study with Solea CO2-9.3μm short-pulsed 
laser - A randomized, single blind, prospective, split mouth 
controlled, clinical trial. 
Trial registration 
to be registered on ClinicalTrials.gov 
Protocol Number: 
ClinFCaries05-2014 - Final as of April 2015 
Investigational Product: Convergent CO2 9.3μm short pulsed laser 
Indication: 
Prevention of fissure caries  
Funding: 
Convergent Dental Grant  
through Office of Innovation, Technology and Alliances at UCSF 
Source of Funding: 
 
Secondary Sponsor: 
 
Development Phase: 
Phase II study 
Sponsor's Responsible 
Medical Officer: 
 
 
 
Sponsor Signatory: 
 
Effective Date: 
 
 

Fissure Caries Inhibition Study Solea CO2-9.3μm short-pulsed laser 
 
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2. 
SYNOPSIS 
 
Study Title: Fissure Caries Inhibition Study with Solea CO2-9.3μm short-pulsed laser –  
 
 
 
A randomized, single blind, prospective, split mouth controlled, clinical trial 
Protocol number: CFCaries05-2014  - Final as of April, 2015 
Investigators:  
Peter Rechmann, DMD, PhD,  
 
 
 
 
Krunal Sherathiya, DDS 
 
 
 
 
John D.B. Featherstone MSc, PhD  
Study center: University of California at San Francisco 
Multicenter study  
[ ] Multicenter 
Coordinating center or the prime grant holder: 
Other Centers: 
Study Sites: 
Study period: 08-2014 to 04-2017 
Phase of development: phase II 
 
Investigational Product: Convergent CO2 9.3μm short pulsed laser 
Indication: 
Prevention of dental caries in fissures 
IND/IDE numbers: 
 
Who holds the IND/IDE? 
[ ]Sponsor  
[ ]Investigator 
 
The study design and protocol closely follows the SPIRIT 2013 – “Standard Protocol Items: 
Recommendations for Interventional Trials” - Recommended items to address in a clinical trial protocol 
and related documents.1 
The study results will be reported according to the CONSORT 2010 Statement - guidelines for reporting 
parallel group randomized trials.2 
 
STUDY DESIGN – Draft 
Objective:  The objective of this clinical study is to evaluate whether the use of the new CO2 
- 9.3μm short-pulsed laser increases the caries resistance of occlusal pit and 
fissure surfaces in patients in addition to fluoride therapy quantified by visual 
exams with the International Caries Detection and Assessment System (ICDAS 
II), SOPROLIFE daylight and blue fluorescence, and DIAGNOdent Laser Light-
induced Fluorescence in a randomized, single blind, prospective, split mouth 
controlled, clinical trial over 12 months. 

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Hypothesis:   
The hypothesis to be tested is that treatment with the new CO2 - 9.3μm short-pulsed 
laser in addition to fluoride therapy results in changes in crystal composition and 
structure which increase the resistance of dental mineral to dissolution by acid and will 
work to better prevent dental caries in the occlusal surface of vital teeth when 
compared to fluoride therapy alone over 12 months (detailed outcomes see below). 
Background and Rational 
Over the last two decades caries prevalence in the permanent dentition has declined nearly 
ten percent in American children aged 9-16.3  While this remarkable decrease in caries is 
significant, 42% of the population in this age range is affected by dental caries.3 Nearly 80% 
of all of carious lesions in adolescences involve the occlusal pits and fissures.4 Currently, 
there are two common professionally delivered techniques towards caries prevention: pit and 
fissure sealants, and topical fluoride.  Other interventions such as diet counseling or oral 
hygiene instruction are highly dependent on daily patient compliance.  The high proportion 
of occlusal decay suggests that current preventive practices are inadequate whether it is due 
to the method, technique or patient access to preventive care.   
 
Methods of early caries detection 
Current commonly used caries detection methods in the United States include visual 
inspection, tactile use of the explorer, and radiographs.  Studies in Europe have shown that 
the explorer is only correct less than 50% of the time.5 Radiographs are good for 
interproximal caries, but ineffective in detecting occlusal caries before it is well into the 
dentin due to the amount of sound tissue attenuating the beam6.  By the time an occlusal 
caries lesion is detectable radiographically, it is too large to be remineralized6.  If carious 
lesions are detected early enough, intervention methods, such as fluoride application, 
sealants, preventive resin restorations, laser treatment, and antibacterial therapy, can be 
applied to reverse the caries process.6  
Visual inspection can be very subjective based on clinician experience and training.  
Standardized visual inspection systems should be adopted to avoid inconsistencies amongst 
diagnoses from different dentists.  The International Caries Detection and Assessment 
System (ICDAS) provides a standardized method of lesion detection and assessment, leading 
to caries diagnosis.7-10 ICDAS II assigns scores to lesions based on apparent caries status and 
lesion severity of plaque-free teeth when visualized wet and when air dried.7 Of particular 
interest to this study are the coronal primary caries detection criteria.  The ICDAS II 
detection codes for coronal pits and fissures caries range from 0 to 6 as follows7 (pictures 
and details see below). 
 
Fluorescence is a property of some manmade and natural materials that absorb energy at 
certain wavelengths and emit light at longer wavelengths. Laser fluorescence is a new 
method for early caries detection.  By analyzing the fluorescence emission spectrum of 
carious regions versus sound tissues, studies have shown that laser fluorescence is useful as a 
quantitative measure distinguishing carious from non-carious surfaces.6   
Three main methods of laser fluorescence have been studied: quantitative light-induced 
fluorescence (QLF) (blue light),11-16 KaVo DIAGNOdent (red light),17-23 and SOPROLIFE in 

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blue fluorescence mode.24, 25  
The QLF method has been tested in several in vitro,26-28 in situ,29 and in vivo11-16 studies for 
smooth surface caries lesions. The possibility of adapting the QLF method for occlusal caries 
diagnosis is under investigation.30 On occlusal lesions the discrimination between the 
severities of carious lesions has been shown to be insufficient.24  
The DIAGNOdent system has shown good performance and reproducibility for detection and 
quantification of occlusal and smooth surface carious lesions in in vitro studies,31-33 but with 
somewhat more contradictory results in vivo, both in the primary and permanent dentition.17-
23 It has also been tried for longitudinal monitoring of the caries process, and for assessing 
the outcome of preventive interventions.34 
SOPROLIFE in daylight and blue fluorescence mode has demonstrated its capability to 
efficiently visualize caries lesions in early, pre-cavitated stages and thus allows scoring of 
pre-cavitated lesion stages.24, 25 
Evidence regarding rendering enamel caries resistant by use of a short-pulse CO2-
Laser 
Featherstone and co-workers have shown, in several studies, that enhancement of caries 
resistance of enamel can be achieved in the laboratory by irradiation with short-pulsed CO2-
lasers under well-specified irradiation conditions 35-37 using much lower energy levels than 
those reported in other studies. Using the same laser irradiation conditions in a “pulpal safety 
study” on teeth in humans evidence was provided that there is no harm to the pulpal tissue of 
those irradiated teeth.38 
Rechmann and co-workers used an orthodontic bracket model 39 and showed, for the first 
time in vivo, in a single blind, prospective clinical trial that enhancing enamel 
demineralization resistance can be achieved by irradiation with a CO2 9.6 μm laser, emitting 
laser pulses in the microsecond range.40 The quantitative assessment of demineralization by 
cross sectional microhardness testing of laser treated enamel revealed that using a 9.6 µm 
CO2-laser irradiation significantly inhibited the formation of carious lesions around 
orthodontic brackets. It was shown that the laser irradiation reduced enamel mineral loss by 
up to 46% over a time period of 4 weeks, and up to an 87% over 12 weeks in comparison to 
the control surfaces, which was speculated to be also related to an enhancement of 
remineralization following the laser irradiation.40 
Lately, the group has shown in a single blind, controlled, randomized, clinical split mouth 
pilot trial on 20 subjects that using a microsecond pulsed 9.6 µm CO2-laser with additional 
fluoride varnish applications significantly inhibits the formation of carious lesions in fissures 
of molars in vivo in comparison to a non-irradiated control tooth in the same arch over a one 
year observation interval.41 At all recalls, average ICDAS scores had decreased for the test 
and increased for the control fissures (laser vs. control, 3-month: -0.10±0.14, 0.30±0.18, 
P>0.05; 6-month: -0.26±0.13, 0.47±0.16, P=0.001; 12-month: -0.31±0.15, 0.75±0.17, 
P<0.0001; mean ± SE, t-test). SOPROLIFE daylight evaluation revealed at 6- and 12-month 
statistically significant differences in changes between baseline and recall for test and control 
molars, respectively (laser vs. control, 6-month: 0.22±0.13, 0.17±0.09, P=0.02; 12-month: 
0.28±0.19, 0.25±0.17, P=0.03). For SOPROLIFE blue-fluorescence evaluation mean 
changes in comparison to baseline for the control and the laser treated teeth were also 
statistically significant for the 6- and 12-month recall.  

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Explanation of Rationale with justification for undertaking the trial 
In summary there is sufficient evidence that during CO2 short-pulsed laser irradiation the 
outer few micrometers of enamel are thermally transformed from a carbonated 
hydroxyapatite into a more acid resistant hydroxyapatite.42-44 This is advantageous since it 
increases resistance to acid dissolution and thus inhibits tooth decay.  
The clinical study presented here will show that using a CO2 9.3μm short pulsed laser 
irradiation markedly inhibits caries progression in pits and fissures in comparison to fluoride 
varnish alone over 12 months. 
 
Study Design 
[x]Randomized  [ ]Investigational intervention without random assignment 
[x]Blinded, Single, [ ]Blinded, Double 
[x]Prospective  [x]Control   [ ]Behavioral 
Study’s formal designation: 
[ ]Phase I 
[x]Phase II [ ]Phase III [ ]Phase IV 
Framework: 
[x] superiority 
[ ] equivalence 
[ ] non inferiority [ ] exploratory 
_______________________________________________________________________________ 
Study type 
The CHR application will be a minimal risk, full committee review application. 
Methodology 
Specific Aims 
A) The aim of the study is to assess if the use of the new CO2 - 9.3μm short-pulsed laser 
in addition to fluoride therapy allows rendering occlusal pit and fissures caries 
resistant in comparison to fluoride therapy alone in participants in a randomized, 
single blind, prospective, split mouth controlled, clinical trial. The fissure mineral 
loss will be quantified by visual exams with the International Caries Detection and 
Assessment System (ICDAS II), SOPROLIFE daylight and blue fluorescence, and by 
DIAGNOdent Laser Light-induced Fluorescence.  
Primary study outcome measures 
Differences in change in ICDAS scores between matched case and control teeth (within 
patient) from baseline to 6 months and baseline to 12 months 
Differences in occurrence of ICDAS 3 scores between matched case and control teeth 
(within patient) from baseline to 6 months and baseline to 12 months 
Secondary study outcome measures 
Differences in change in SOPROlife scores between matched case and control teeth (within 
patient) from baseline to 6 months and baseline to 12 month 
_________________________________________________________________________________ 

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Material & Methods 
Clinical Study: 
This project will be a single blind, controlled clinical split mouth study.  Patients meeting the 
inclusion criteria from the UCSF Predoctoral, Postgraduate Pediatric Dental and 
Postgraduate orthodontic clinics will have the study explained to them and be invited to 
participate.  The Caries Management By Risk Assessment (CAMBRA) questionnaire will be 
used to access the caries risk status at baseline.  Patients with moderate/high caries risk will 
be invited to enroll into the study.  The molar on their dominant side (right or left) will be 
randomly assigned to either the test or the control group with the contralateral non-dominant 
side receiving the other treatment. A baseline visual inspection using ICDAS II, white and 
blue light digital photographs (SOPROLIFE), and DIAGNOdent assessments will be made 
by a dentist blinded to randomized group prior to treatment. The test tooth/teeth will be 
treated with CO2 laser irradiation and fluoride varnish; the control tooth/teeth will receive 
fluoride varnish treatment alone.  The patient will be asked to return for a 6-month and a 12-
month follow up exam, at which time visual inspection with all testing methods will be 
conducted by the dentist who originally completed the baseline exam.  The endpoint of the 
study for each participant will be when either the control or test tooth is found to have 
significant demineralization by ICDAS assessment (ICDAS code 3 – “localized enamel 
breakdown without clinical visual signs of dentinal involvement”) or at the 12 month exam, 
whichever comes first. The control and test teeth might be sealed with a dental sealant at the 
end of the study.  All data obtained will be analyzed for statistical significance. 
 
Subjects 
Participants in the study will be patients, who have at least one pair of contralateral unsealed 
molars (first) showing ICDAS score 0, 1, or 2. 
Subjects will be of moderate or high caries risk according to Caries Risk Assessment.  
Information on the child’s dental visit history, tooth brushing habits, and snacking habits will 
be collected through a questionnaire. The appropriate UCSF questionnaire45 and/or the 
MyCAMBRAR App (Apple AppStore, Cupertino, CA) will be used to assess the Caries Risk. 
Age limitation for the study is ≥ 6 years. 
 
Settings and locations where data will be collected 
The subjects will be recruited from the UCSF School of Dentistry. They will be recruited 
from the UCSF Predoctoral, Postgraduate Pediatric Dental and Postgraduate orthodontic 
clinics. The Pediatric Dentistry Clinic sees 200 to 300 patients in need of multiple fissure 
sealants per year. Approximately 2,500 sealants are placed every year. (There are reasons 
why sealants are not placed; these patients will be eligible for this study described here – see 
below.) 
 
Subjects will be visiting the dental clinics for a new patient visit or a periodic oral exam. 
Subjects will have at least one pair of contralateral molars (first) in need of fissure sealants. 
Subjects will be treated in the Pediatric Dentistry and in the PRDS facilities.  
 
Experimental Design 
Enrollment, Consenting & Randomization: Flyers posted in the School of Dentistry will be 

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used to recruit patients and study investigators (and/or staff) will recruit their own patients 
directly in person (outside the direct treatment area). 
When patients are seen by their dentist and the treating dentist believes that the patient might 
fit into the study, he/she will ask the potential participant (and parent/guardian for minors) 
whether she/he might be interested in being in a dental study. If the subject is interested the 
treating dentist will ask the potential participant (and parent/guardian for minors) whether 
she/he gives permission to disclose her/his name to the researchers. If the patient agrees (and 
parent/guardian for minors), a Clinical Investigator (Peter Rechmann, Krunal Sherathiya) 
and/or the Clinical Study Coordinator (Beate Rechmann) will ask the potential subject 
whether she/he is interested in participating in this study. If so the Clinical 
Investigator/Clinical Study Coordinator will explain the whole study and will further check 
for eligibility. 
Consenting all study subjects and their parents/guardians will take place prior to entering the 
study. Potential participants will be consented and enrolled by the PI/I, and a senior research 
associate, respectively.  
To achieve adequate participant enrolment to reach targeted sample size, advertisements will 
be placed in the Pediatric Dentistry Clinic area as well as in other patient areas of the School 
of Dentistry.  
In the Division of Pediatric Dentistry the recommendations are to treat first molars with 
fissure sealants. Nevertheless, sometimes patients cannot afford or do not want the sealant 
treatment. In addition, anatomical conditions with tissue overgrowth on the distal side of the 
molar sometimes do not allow placing a sealant. These are potential situations for using the 
CO2-laser to render the fissure enamel caries resistant. Thus the intended study does not 
interfere with the typical treatment.  
 
The interventions - treatment groups 
Each tooth of a molar pair in the same jaw will be randomly assigned to one of the 2 
different treatments.  
The study treatments are: 
1)  CO2 9.3 μm short pulsed laser rendering fissure areas more caries resistant (using 
proven laser settings) plus fluoride treatment (experimental group) 
2) Fluoride treatment alone (control group) 
  
- All study teeth will receive F-varnish application at baseline and every 6 months 
 
Randomization of study teeth – allocation concealment 
After enrollment subject’s molars will be randomly assigned to the experimental or control 
group. The molar on the dominant side (right or left) will be randomly assigned to either the 
test or the control group with the non-dominant (contralateral) side receiving the other 
treatment.  This is because dominant side determined by handedness may relate to oral 
hygiene. 
A study independent person will create a randomization list, which will be created by a 
random number generator (QuickCalcs Online Random Numbers by GraphPad Software, 
Inc.).46 The randomization list will be kept locked by a dental assistant (DA), group 
assignments will be in separate, closed opaque, sequentially numbered envelopes; only after 

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a subject has been enrolled the next-in-line group assignment will be revealed.  
 
Blinding 
The doctor performing the laser treatment and the dental assistant (DA) will not be blinded to 
subjects’ group assignment and will explain the assignment to the subjects. The participant 
will also not be blind to the treatment. The DA will inform the laser treating doctor, which 
tooth will be the intervention and which the control tooth.  
An independent study investigator will be blinded to subjects’ group assignments. The DA 
will serve as the go-to person for subjects.  
The statistician will be blinded to treatment assignment by (randomly) labeling the 2 groups 
as 0 and 1, without giving the statistician the key. 
 
Study duration 
The total study duration for each subject will be 12 months. 
 
Testing methods 
The following tools for assessments will be used: 
a. Filling out the UCSF CAMBRA form (standard form used in the UCSF 
predoctoral clinic – evaluating habits and risks related to caries). 
b. Visual clinical examination and assessment 
 
using 2x magnification loops, dental mirror and dental unit light for 
caries assessment using ICDAS II criteria* (at baseline ICDAS 0 – 2); 
c. SOPROlife**daylight intraoral camera; SOPROlife day light mode, picture 
recorded with Sopro-imaging software (Acteon, Sopro, La Ciotat, France) 
- allowing independent observers to judge SOPROlife daylight score25 
later on; 
d. SOPROlife fluorescence mode, picture recorded with Sopro-imaging 
software fluorescence measurements using blue light fluorescence 
(SOPROlife) – SOPROlife blue fluorescence score25;  
e. DIAGNOdent (KaVo, Biberach, Germany) light fluorescence device (red 
fluorescence); 
f. digital photography. 
* Table 1– ICDAS classification and definition 
ICDAS code 
0 
 
1 
 
2 
3 
Definitions 
Sound tooth 
surface; no caries 
change after air 
drying (5 sec); or 
hypoplasia, wear, 
erosion and other 
non-caries 
First visual 
change in enamel; 
seen only after air 
drying, or colored 
change “thin” 
limited to the 
confines of the pit 
Distinct visual 
change in enamel; 
seen when wet, 
white or colored, 
“wider” than the 
fissure/fossa. 
Localized enamel 
breakdown, with 
no visible dentin 
or underlying 
shadow; 
discontinuity of 
surface enamel, 

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** SOPROLIFE - The SOPROLIFE system (SOPRO, ACTEON Group, La Ciotat, France) combines 
the advantages of a visual inspection method with a high magnification oral camera and a laser 
fluorescence device. This technique is based on the LIFE DT concept (Light-Induced 
Fluorescence Evaluator - Diagnostic and Treatment).47, 48 In the “daylight mode” white LEDs 
illuminate the tooth while in the “fluorescence mode” the excitation is managed by four blue 
LEDs at 450nm wavelength. The intense blue light shines through the enamel and induces a 
green fluorescence from the dentin core, which then consequently initiates on its way back 
through dentin/enamel a red fluorescence due to porphyrins and related compounds from oral 
bacteria remaining at a caries lesion site.25  
 
Testing times 
The evaluation of the fissures will occur  
- at baseline ((before and after laser treatment) 
- at the end of 6 and 12 months 
 
Study duration 
The total study duration for each subject will be 12 months 
 
Data collection methods 
Data will be collected on individualized Case Report Forms (CRF). Case report forms will be 
detailed for baseline and all recall intervals. Data will be transferred into electronic files for 
data analyses. After data transfer, a second person will check for correctness of data transfer. 
 
Inter and intra-examiner reliability 
The independent evaluator(s) and a study doctor/evaluator will be trained and calibrated on 
the ICDAS criteria. The training and calibration will occur on pictures as well as on patients 
in the Pediatric Dentistry Clinic or in PRDS. Evaluators will examine the same patients to 
establish an intra-examiner reliability score. They also will examine the same participant at 
two different time intervals, ideally two to four weeks separate. This will allow for intra 
examiner reliability score evaluation.  The training and calibration will occur before this 
study will be started as well as during the study. 
 
Data management 
To ensure confidentiality of the data, the data will be labeled with study numbers in place of 
subject identifiers, the data will be stored in a locked cabinet within a locked office, and any 
electronic data will be stored on a password protected computer. Data will be kept in locked 
files, which are in locked offices accessible only for the PI and authorized study personal.  
 
Data monitoring 
There is no need for monitoring data or safety. The study is neither invasive nor will any 
invasive treatments be performed. There is no testing of any drugs. The CO2 short-pulsed 
laser has been tested and proven for clinical safety49, has FDA approval for hard tissue 
removal and has been shown efficient for enhancing caries resistance in clinical studies.40, 50 
phenomena. 
and fissure area. 
widening of 
fissure. 

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As regular Pediatric Dentistry patients, the subjects will be monitored closely every 6 
months. Thus any unusual issues will be evaluated in a timely fashion. In addition, simple 
dental indices will be evaluated concerning the visible occlusal surfaces of permanent 
molars. "Light" diagnostic with blue light camera tools and digital photography will be 
performed.  
As always required, the PI will review all adverse events as they occur and will report any 
serious and/or unexpected ones to the CHR within 10 working days, as required by the CHR. 
 
 
Auditing 
The Sponsor will audit the study. 
 
Eligibility criteria for participants 
1. Inclusion Criteria 
• 
age 6 or older, in good general health 
• 
subject is of moderate or high caries risk according to CAMBRA 
• 
has at least one pair of unsealed molars in at least one jaw with need for a sealant  
• 
teeth with an ICDAS code 0, 1 and 2 with deep grooves and fissures providing an anatomical 
stick for an explorer  
• 
willing to comply with all study procedures and protocols  
• 
must be able to read and understand English 
• 
have an understanding of the study 
• 
residing in San Francisco or other nearby locales with community water fluoridation (to eliminate 
water fluoridation as a potential confounding variable) 
• 
patient and parent/guardian able to provide written informed consent in English 
• 
willing to sign the “Authorization for Release of Personal Health Information and Use of 
Personally Unidentified Study Data for Research” form; data will only be used for research. 
2. Exclusion Criteria 
• 
show evidence of extremely poor oral hygiene 
• 
subjects suffering from systemic diseases, significant past or medical history with conditions that 
may affect oral health or oral flora (i.e. diabetes, HIV, heart conditions that require antibiotic 
prophylaxis),  
• 
subjects with Nut Allergy 
• 
taking medications that may affect the oral flora or salivary flow (e.g. antibiotic use in the past 
three months, drugs associated with dry mouth / xerostomia [extreme high caries risk])  
• 
other conditions that may decrease the likelihood of adhering to study protocol 
• 
subjects who will leave the area and are unable to complete the study 
_________________________________________________________________________________ 
Sample size calculation & statistics 
Sample size calculations are performed by UCSF Department of Epidemiology and 
Biostatistics using PASS 12 Power Analysis & Sample Size Software 
(http://www.ncss.com/software/pass/). 
We assume that we will enroll into the suggested in-vivo occlusal caries prevention 
by short-pulsed CO2 9.3 μm laser prospective, randomized, single blinded clinical study 

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roughly 70 to 80 subjects.  
Power calculations below are based on results obtained from our pilot study on caries 
prevention 51  (Rechmann, P., et al, "In-vivo occlusal caries prevention by pulsed CO2 -laser and 
fluoride varnish treatment - a clinical pilot study," Lasers in Surgery and Medicine 45(5), 302-310 
(2013)). For the purpose of sample size calculation, we assume a simple measure based on 
our primary endpoint of change in ICDAS scores with only one pair of molars per subject, by 
comparing the proportion of teeth with worsening ICDAS score in laser vs. control groups. 
(We actually expect some subjects to provide more than one pair of molars, which will add 
to the power.) Note that we will actually use a generalized linear mixed model (proportional 
odds) for the primary analysis based on differences in scores, but there are no general power 
analysis software procedures for that test. Therefore, we use this simpler and less powerful 
metric to conservatively guide power considerations. In the pilot study we observed 1 
participant with worsening ICDAS score in the laser group vs. 9 participants in the control 
group. We determine power based on a McNemar test to account for the pairing of 
observations. The observed difference in ratio for worsening ICDAS score was 0.56 (0.06 
laser vs. 0.62 control). With a conservative sample size of 50 (after loss to follow up) and 
assuming the same proportion of discordant pairs (75%), we would have 80% power to 
detect a difference in proportions of 0.35 at the 5% significance level (i.e. allowing for over 
35% reduction in the pilot observed difference of 0.56). Furthermore, we expect to improve 
power further by working with the actual ICDAS scores and using the Wilcoxon signed-rank 
test (the extra power comes from being able to capture the extent of worsening in each case).  
 
_________________________________________________________________________ 
Data Analysis - by UCSF Department of Epidemiology and Biostatistics. 
The primary analysis of this study will compare ICDAS scores for the laser group vs. 
controls. To this end, we will perform mixed effects proportional odds regression modeling 
with outcomes of ICDAS and SOPROLIFE scores. These models will explicitly account for 
within patient clustering and will include group (laser vs. control) as the main predictor along 
with tooth site and additional potential moderating variables such as age, sex, snack habit 
measures, tooth brushing habit, and dental history predictors. Importantly, we will include 
interactions of these additional predictors with the group predictor as well as time, which 
may indicate whether there is possible differential protectiveness of laser (over time) in 
specific subgroups. The models will be explored in a bottom up approach with each predictor 
considered in models one at a time along with group, group by predictor interaction and 
tooth site. If we see important effects, we will then combine a small number of predictors 
based on scientific plausibility in a single model, though we note that these will be far from 
definitive models given the sample size and scope of the proposed study. P<0.05 will be 
considered statistically significant though we will emphasize that any model results are 
highly speculative and will require independent verification. 
________________________________________________________________________________ 
IRB approval 
Investigational Review Board approval (UCSF Committee on Human Research CHR) will be 
achieved before the study will be started. 

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If requested the IRB can additionally scrutinize the study and will state that the study was conducted 
under the rules of GCP - Good Clinical Practice.  
 
_________________________________________________________________________________ 
 
 
 
References 
[1] 
Chan, A. W., Tetzlaff, J. M., Altman, D. G., Laupacis, A., Gotzsche, P. C., Krleza-Jeric, K., Hrobjartsson, 
A., Mann, H., Dickersin, K., Berlin, J. A., Dore, C. J., Parulekar, W. R., Summerskill, W. S., Groves, T., 
Schulz, K. F., Sox, H. C., Rockhold, F. W., Rennie, D. and Moher, D., "SPIRIT 2013 statement: defining 
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