Exploring How U.S. Dental Schools Teach Removal of Carious Tissues During Cavity Preparations

Utilization of 3D evaluation for assessing selective caries removal practice in pre-clinical dental students: a pilot study

BACKGROUND

Practicing and assessment of selective caries removal techniques in dental students remain challenges in many dental schools. The aim of this study was to utilize a 3D assessment technique, within a designated acceptable range of deviation, to evaluate the tendency of dental students in performing selective caries removal (SCR). The correlation between 3D assessment results and the conventional rubric rated by an instructor was also determined.

METHODS

Fifth-year dental students (n = 61) performed the SCR task on 3D-printed teeth containing simulated deep caries lesions in occlusal and proximal surfaces. One instructor assessed the results using a conventional analytic rubric. The excavated teeth were additionally evaluated using 3D analysis software with the designated acceptable range of deviations (± 0.5 mm) from the standard cavities. The average root mean square (RMS) value, representing the deviation between student-prepared cavities and the predefined standard cavities, was recorded. A tendency towards over-excavation was defined for RMS values > 0.5 mm, and towards under-excavation for RMS values < 0.5 mm.

RESULTS

The mean (min-max) of RMS was 0.27 (0.18-0.40) for occlusal and 0.29 (0.20-0.57)for proximal cavities. A tendency of dental students toward over-excavation was observed in both occlusal (74%) and proximal cavities (87%). There was a moderate negative correlation between the RMS values and the traditional rubric scores for both occlusal (R2 = 0.148, P = 0.002) and proximal cavities (R2 = 0.107, P = 0.010).

CONCLUSIONS

The 3D evaluation technique effectively revealed specific tendencies in dental students' caries removal skills. The integration of computerized assessments with traditional methods could potentially assist the instructors in delivering more objective and specific feedback to students. Further research is encouraged to investigate the impact of this assessment technique on improving student performance in selective caries removal skills.

Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association

BACKGROUND

An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth.

TYPES OF STUDIES REVIEWED

The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations.

RESULTS

The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios.

PRACTICAL IMPLICATIONS

The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.

Assessment of 3D-Printed Tooth Containing Simulated Deep Caries Lesions for Practicing Selective Caries Removal: A Pilot Study

A standard model for practicing caries removal skills is needed to support learners in managing deep carious lesions. The aim of the current study was to prepare 3D-printed teeth with added simulated carious layers and a pulpal structure. A first permanent mandibular containing occlusal (Class I) or proximal (Class II) cavities was printed. The teeth were then filled with wax and resin-modified glass ionomer cements mixed with a color modifier to simulate pulp and deep caries, respectively. Undergraduate dental students (n = 61) were asked to remove the caries using the selective caries removal (SCR) technique on the teeth. The students then completed a self-administered questionnaire to rate their caries removal experiences. One instructor then assessed the prepared teeth. Overall, the students provided positive feedback on the use of 3D-printed teeth; 72.1% agreed that the printed teeth provided a realistic model for practicing the SCR technique, 75.4% indicated that the new teeth were the appropriate choice for practicing the SCR technique, and 86.9% agreed that 3D-printed teeth should be used before treating real patients. More than half of the students had satisfactory outcomes in terms of the depth and caries removal aspects of the cavity preparation. These findings suggest that the developed 3D-printed teeth can potentially be adopted to practice caries removals in preclinical dental education.

Current Strategies to Control Recurrent and Residual Caries with Resin Composite Restorations: Operator- and Material-Related Factors

This review addresses the rationale of recurrent and/or residual caries associated with resin composite restorations alongside current strategies and evidence-based recommendations to arrest residual caries and restrain recurrent caries. The PubMed and MEDLINE databases were searched for composite-associated recurrent/residual caries focusing on predisposing factors related to materials and operator’s skills; patient-related factors were out of scope. Recurrent caries and fractures are the main reasons for the failure of resin composites. Recurrent and residual caries are evaluated differently with no exact distinguishment, especially for wall lesions. Recurrent caries correlates to patient factors, the operator’s skills of cavity preparation, and material selection and insertion. Material-related factors are significant. Strong evidence validates the minimally invasive management of deep caries, with concerns regarding residual infected dentin. Promising technologies promote resin composites with antibacterial and remineralizing potentials. Insertion techniques influence adaptation, marginal seal, and proximal contact tightness. A reliable diagnostic method for recurrent or residual caries is urgently required. Ongoing endeavors cannot eliminate recurrent caries or precisely validate residual caries. The operator’s responsibility to precisely diagnose original caries and remaining tooth structure, consider oral environmental conditions, accurately prepare cavities, and select and apply restorative materials are integral aspects. Recurrent caries around composites requires a triad of attention where the operator’s skills are cornerstones.

Preclinical 3D-printed laboratory simulation of deep caries and the exposed pulp reduced student anxiety and stress, while increasing confidence and knowledge in vital pulp treatment

Aim

To evaluate the impact of a preclinical laboratory session using 3D printed teeth on dental student stress, anxiety, confidence and knowledge when treating deep caries and pulp exposure.

Methodology

This was a two‐centre controlled study, with randomized distribution of students into two groups: a vital pulp treatment (VPT) lecture‐only (control) group and a VPT‐lecture combined with a VPT‐laboratory (experimental) group. In both universities, preclinical students with endodontic or operative dentistry laboratory sessions could participate. All students were invited to the lecture. Two weeks later (timepoint‐T1), both groups completed validated and bespoke questionnaires and scales to evaluate their stress (Stress‐VAS), anxiety (STAI Trait [T] and State [S]), self‐confidence and knowledge. Thereafter, only the experimental group attended the hands‐on laboratory session demonstrating the techniques of selective caries removal and partial pulpotomy on a commercial 3D‐printed tooth. Two weeks later (timepoint‐T2), the participants from both groups repopulated the same questionnaires and VAS. The control group had the laboratory session after the completion of the study. The statistical analysis was performed with Statistica® (significance p = .05). The homogeneity between the two samples was checked by Khi² and Student tests. Stress‐VAS, STAI‐S, confidence and knowledge scores were compared within each group, and between the two groups, at T1 and T2, with a repeated measures anova test (+/−Tukey post‐hoc test).

Results

The groups comprised 54 students each, with no statistical difference between the groups regarding demographic, academic data and STAI‐T score. The two groups had no significant difference of Stress‐VAS, STAI‐S, confidence and knowledge scores at T1 while they presented a significant difference in stress, anxiety and confidence scores at T2, but with no significant difference in knowledge score. However, knowledge score, as other parameters, improved significantly between T1 and T2 in the experimental group.

Conclusions

The addition of a laboratory session using 3D‐printed teeth that simulated deep caries and pulp exposure management, significantly reduced the stress and anxiety of students and increased their confidence. Within the limitations of this study, the benefit of introducing new technology in increasing student confidence and reducing stress offers opportunity for educational improvement in the VPT and cariology areas.

Pilot study assessing 3D-printed teeth as a caries removal teaching tool

INTRODUCTION

In UK universities, caries removal teaching utilises plastic teeth. This format does not enable students to learn how to distinguish between tooth layers and caries via tactile feedback. The aim of this study was to assess the applicability of a novel, 3D-printed carious tooth within caries removal teaching.

MATERIALS AND METHODS

Single-material 3D-printed teeth containing simulated tactile caries were developed and 14 final-year undergraduates were briefed to remove caries and minimise damage to healthy tissue within the tooth. Students completed evaluation questionnaires for their opinion of 3D-printed teeth in comparison to plastic teeth and perceived confidence to subsequently treat patients. Cavity preparation perimeters were measured, using photographs with a standard protocol. Heat map analysis illustrated variation in location and extent of cavity preparations produced by the cohort.

RESULTS

Student feedback indicated the 3D-printed caries exercise was positively received, 71.4% agreed 3D-printed teeth would have better prepared students for patient treatment; 78.6% rated their preclinical stress/anxiety as 'very high' or 'high' and 57.1% agreed that if preclinical teaching incorporated 3D-printed teeth, their stress/anxiety when treating their first caries patient would have been reduced. The average perimeter of cavity preparation indicated relative variation, with a maximum perimeter of 19.6 mm and a minimum of 10.7 mm, and a range of 8.9 mm.

DISCUSSION

Introducing 3D-printed teeth into preclinical teaching would allow students to gain confidence in clinically relevant experience in tactile aspects of caries treatment earlier in their training than currently possible.

CONCLUSION

This study demonstrates student acceptance of an alternative caries removal teaching method, with potential to increase aptitude in caries removal in a clinically relevant manner.

Variability in caries management decision-making in a dental school setting

OBJECTIVE

To assess variability in caries management decision-making by faculty and dental students. Understanding sources of variability during training can aid in implementing evidence-based clinical decision-making in caries management.

METHODS

A voluntary, anonymous survey including clinical scenarios was distributed online to dental students in their first (D1) and third-year (D3) of training, and to faculty in the Department of Cariology, Restorative Sciences and Endodontics.

RESULTS

The response rate was 100% (108/108) for D1 students, 56% (73/130) for D3 students, and 39% (34/88; 12 full-time and 22 part-time) for faculty. D1 students, who were completing a cariology course, were in general more conservative in restorative thresholds for less severe caries lesions than D3 students and sometimes clinical faculty (e.g., for lesions at the DEJ, a significantly [p < 0.05] higher percentage of D3 students would restore these [53%] compared to D1 students and faculty [19% and 18%, respectively; p > 0.05]). For all groups, the threshold for doing restorative intervention was shifted toward less severe caries lesions as the caries risk increased (e.g., very few respondents would restore an occlusal lesion confined to enamel, with significantly [p < 0.05] less percentage of D1 students [lower risk scenario-LR = 4%; higher risk scenario-HR = 22%] compared to D3 students and faculty [LR = 15% and 18%; HR = 66% and 62%, respectively; p > 0.05]). Class lectures/preclinical instructors were the most important factor influencing decision-making for D1 students, versus clinical experiences/instructors for D3 students.

CONCLUSION

Although the majority of respondents used best-evidence deciding caries management, there was variability in how to manage less severe lesions, with caries risk influencing clinical thresholds, and clinical experiences influencing students' decision-making over time.

Minimum intervention dentistry in the US: an update from a cariology perspective

Despite evidence strongly supporting use of non-invasive or minimally invasive procedures in caries management, there is still a large gap between evidence-based recommendations and application of these concepts in practice, with the practice of dentistry still largely dominated by invasive procedures in the US. This paper describes efforts in education and clinical practice in the US in the last decade to promote evidence-based cariology strategies, which support a minimum intervention dentistry (MID) philosophy. These include, for example: a competency-based core cariology curriculum framework which has been developed and disseminated. National education accreditation standards supporting caries management are likely to soon be changed to support assessment of best evidence in cariology. There are several ongoing efforts by organised dentistry and other groups involving dental educators, researchers and clinical practitioners to promote cariology concepts in practice, such as the development of evidence-based clinical practice guidelines for caries management by the American Dental Association. Within each of these strategies there are challenges, but also opportunities to expand the implementation of MID in the US, which create optimism for future improvements over time.

Investigating the construct validity of a haptic virtual caries simulation for dental education

Introduction

Teaching dental caries removal is limited by the material and methods available in the preclinical teaching space. Plastic teeth do not simulate the tactile feel of a lesion and natural teeth do not allow for standardised training and assessment. A novel method for simulating caries has been reported. Here, to investigate the construct validity of a caries simulation, whether haptic simulation could contribute to the understanding of caries removal, the performance of first-year dental students on the haptic simulation exercise is compared with that of experienced dentists.

Method

A virtual block comprising healthy dentine, pulp, enamel and a carious lesion with significant spread along the amelodentinal junction (ADJ) was developed for the Simodont dental trainer. The case was presented to 112 first-year students and 17 clinicians following a 15 min training period on a block which contained green caries and displayed live progress throughout the exercise. All participants were given the same verbal instructions: to remove all unsupported enamel and caries along the ADJ while retaining as much healthy tissue as possible.

Results

Clinicians performed better than the dental novices in precision and overall performance. Clinicians removed more material on average, except for healthy dentine, of which similar amounts were removed by both groups.

Discussion

We presented a novel haptic caries exercise and investigated the construct validity of the task. The simulation may bridge the gap between preclinical and clinical dental education in caries removal.

Conclusion

Clinically experienced dentists outperformed novices on a haptic caries simulation exercise. The exercise may be a useful tool for assessing conceptual understanding of caries removal.

Predoctoral Dental Education in Tooth Prognosis and Treatment Complexity: A Survey of U.S. Dental Schools

The aim of this study was to determine the educational methods and tools used to teach tooth prognosis and treatment complexity determination in U.S. predoctoral dental programs. In 2018, an online survey was emailed to the academic deans of all 66 accredited U.S. dental schools. Of these, 42 schools responded (63.6%), and 36 schools completed the entire survey (54.5%). The methods reported for teaching tooth prognosis and case complexity determination varied widely among the participating schools. Among the respondents, 25% reported using the American Association of Endodontists' Endodontic Case Difficulty Assessment, while 10% reported having no specific method for teaching prognosis. The most common method for teaching overall treatment complexity was the Prosthodontic Diagnostic Index, which was used by 24% of the respondents. However, another 24% reported that their school did not have a specific method for teaching treatment complexity. Large percentages of the respondents reported that students sometimes or often made wrong tooth prognosis and case complexity determination (90% and 92%, respectively). The most prominent feedback provided by the respondents based on their experience was the importance of faculty standardization, the understanding of students' inexperience, and the need for an interdisciplinary approach. The majority of these respondents reported that their schools had specific methods of teaching prognosis and case complexity determination. However, there was a wide range of teaching practices related to the contents and levels of evidence.

Potassium Iodide Reversal of Silver Diamine Fluoride Staining: A Case Report

This article describes the clinical protocol of using potassium iodide (KI) to reverse staining caused by silver diamine fluoride (SDF). SDF contains silver, fluoride, and ammonia. It has been used to arrest dental caries mainly in pediatric applications. The major drawback of SDF application is the dark staining of both teeth and restorative materials. Hence, its use on adult dentition is limited. Improving the esthetic outcome by stain reduction would greatly enhance the opportunity for SDF's universal use. This case demonstrates how KI can effectively reverse the staining.

Caries Management with the International Caries Detection and Assessment System II: Established Pit and Fissure Lesions

INTRODUCTION

Operative dentistry addresses the surgical management of caries, a significant portion of dental practice. Dental students, who typically develop their skill sets in this important discipline by creating idealized preparations in plastic teeth, are often confused by the wide variety of tooth anatomy and caries presentation they see when they subsequently treat patients. To address this significant clinical transition issue, we developed this resource on preparing the moderate carious lesion using a stepwise, structured technique.

METHODS

This resource consists of a flipped-classroom learning module and associated laboratory activity with an algorithm worksheet to practice critical thinking skills. Prior to the exercise, an interactive tutorial introduces the didactic background. The 4-hour class session starts with a short quiz and review, then learners use the worksheet to prepare and restore their tooth specimens.

RESULTS

Learner response has been very positive. Moreover, faculty note that learners' skills in treating patients in clinic are noticeably higher and require less faculty intervention than was previously the case.

DISCUSSION

Since new national curriculum standards for caries are currently being introduced, in addition to providing instruction to dental students, this resource presents an excellent opportunity to calibrate faculty members, who are a secondary learner group in this exercise, on a standard clinical protocol.