Influence of residual caries and cervical gaps on the survival rate of Class II glass ionomer restorations

2-year survival and cost analysis of occlusoproximal ART restorations using encapsulated glass ionomer cement in primary molars: a randomized controlled trial

BACKGROUND

The survival of ART restorations can be influenced by the choice of the restorative material. The aim of this randomized non-inferiority controlled trial was to compare the 2-year survival rate and cost analysis of two encapsulated glass ionomer cements (GIC) as occlusoproximal restorative materials in primary molars.

METHODS

Children from public schools in Tietê (Brazil), aged 4-8 years with occlusoproximal dentine carious lesions in primary molars were selected and randomly assigned to receive either Equia Forte (EF) or Riva Self Cure (RSC) as restorative materials. Treatment was carried out by two trained final-year dental students in schools following ART premises. Restorations were assessed by a trained and calibrated examiner after 2, 6, 12, 18, and 24 months. The primary outcome was restoration survival after 2 years, analyzed using Kaplan-Meier survival and Cox regression analysis (α = 5%). Professional and materials costs for each group were collected in Brazilian Reais (R$) and converted into US dollars (US$) and analyzed using Monte-Carlo simulation.

RESULTS

A total of 152 children (76 per group) were included in the study, and 121 (79%) were evaluated after 2 years. The overall 2-year restoration survival rate was 39% (EF = 45%; RSC = 32%) with no difference between the groups. The baseline and 2-year total cost of restorations using RSC was lower when compared to EF (incremental cost: US$ 6.18).

CONCLUSION

After two years of follow-up, Riva Self Cure shows comparable restoration survival rates to Equia Forte, being more cost-effective in the Brazilian perspective.

TRIAL REGISTRATION

This randomized clinical trial was registered on ClinicalTrials.Gov - NCT02730000.

Silver modified atraumatic restorative treatment: a paradigm shift in dental caries management

Silver diamine fluoride (SDF) and atraumatic restorative treatment (ART) are treatment modalities that are minimally invasive and used for the prevention and control of dental caries. The amalgamation of these two techniques has led to the development of silver modified atraumatic restorative treatment (SMART). In this approach the carious lesion is restored with glass-ionomer cement (GIC) after SDF application. SMART effectively arrests caries without removing additional tooth structure, making it a promising option for caries management in children who lack cooperative ability.This article reviews the literature on SMART, the evidence regarding its applications in dental practice, its advantages, drawbacks, the scope for research, and clinical use.

Comparative Evaluation of the Survival Rates of Atraumatic Restorative Treatment Restorations Using Bilayer Technique along with Nanofilled Coating in Primary Molars: A Clinical Study

Objective

To enhance the survival rate of atraumatic restorative treatment (ART) restorations using (class I and class II) bilayer technique of placing glass ionomer cement (GIC) along with nanofilled coating (NC) over the restorations, thereby improving longevity.

Study design

A total of 178 primary molars in 67 children were selected and randomly divided into four groups. Group IA was treated with a single layer of GIC, followed by a protective layer of petroleum jelly in class I restoration. Group IB was treated with a single layer of GIC, followed by a protective layer of petroleum jelly in class II restoration. Group IIA was treated with bilayer GIC restoration followed by NC of GC-Coat Plus in class I, whereas group IIB was treated with bilayer GIC restoration followed by GC-Coat Plus in class II. Clinical analysis of all three groups was performed at 1, 3, 6, 9, and 12 months to evaluate the success of treatment procedures using predetermined criteria. Pearson's Chi-square and Kaplan-Meier estimates were utilized to evaluate the success of all four treatment procedures (p < 0.05).

Results

Out of 178 teeth, 33 teeth were in group IA, 36 teeth were in group IB, 43 teeth were in group IIA, and 40 teeth were available for evaluation at the end of the 12-month follow-up period. The overall success was determined to be 81% for group IA, 79.2% for group IB, 79.5% for group IIA, and 88.6% for IIB. At 6th-month follow-up, one clinical failure was observed in groups IA and IB. At 9 months follow-up, two clinical failures were observed in both group IA and group IB and three failures were observed in group IIB. At 12 months follow-up, four clinical failures were observed in group IA, three in group IB and one clinical failure was observed in group IIB. There was no statistically significant difference observed between the success of the four groups, suggesting that either of the techniques can be utilized for ART.

Conclusion

No statistically significant difference was observed between the survival of class I and class II restorations of both the groups, indicating that either single-layer or bilayer technique along with NC can be adopted for the management of dental caries in primary molars using the ART approach.

How to cite this article

Khan N, Garg N, Garg N, et al. Comparative Evaluation of the Survival Rates of Atraumatic Restorative Treatment Restorations Using Bilayer Technique along with Nanofilled Coating in Primary Molars: A Clinical Study. Int J Clin Pediatr Dent 2024;17(S-1):S55-S60.

Compomers for the restorative treatment of dental caries in primary teeth: An umbrella review

OBJECTIVES

This umbrella review comprehensively appraised the evidence on the use of compomers in comparison to other dental filling materials for restorative treatment of decayed primary teeth.

DATA

The literature search was conducted based on the question: "Is the use of compomers as a dental filling material more successful in the restorative treatment of decayed primary teeth than other dental filling materials?" No language restriction was applied and systematic reviews published up to May 2023 were included. The ROBIS tool was used to assess the methodological quality of the included systematic reviews. Data were extracted for narrative synthesis, considering the restoration failure/success outcomes.

SEARCH

Online search was conducted in three databases (PubMed/Medline, Embase and Cochrane library).

STUDY SELECTION

The electronic search yielded a total of 779 publications. Finally, 18 systematic reviews were included in this umbrella review. Four systematic reviews presented a low risk of bias, 11 presented an unclear risk of bias and three presented a high risk of bias. Most systematic reviews presenting low risk of bias reported no difference in the success rates of compomers compared to other dental filling materials used for restoration of decayed primary teeth. Studies that found a significant difference or that made clear recommendations towards the use of compomers were commonly rated with a high risk of bias.

CONCLUSION

Compomers are similar to other dental filling materials for the placement of direct restorations in primary teeth.

CLINICAL SIGNIFICANCE

The results of this umbrella review indicate a similar clinical performance of compomers compared to other materials containing a resin component for direct restoration in primary teeth. Therefore, the choice of restorative material will depend on multiple factors, such as clinician's skills/preferences, patients' wishes, costs, and cavity type/location.

Short-term Clinical and Microbiological Performance of Resin-modified Glass Ionomer Cement Containing Chlorhexidine for Atraumatic Restorative Treatment

Aim

This study evaluated the short-term clinical and microbiological performance of resin-modified glass ionomer cement (RM-GIC) cement containing chlorhexidine (CHX) for atraumatic restorative treatment (ART) in primary teeth.

Materials and methods

The clinical trial was conducted in 36 children that received ART in primary molars either with GIC (group I, n = 18) or GIC containing 1.25% CHX (group II, n = 18). The survival rate of restorations was checked 7 days, 3, and 6 months after their application when saliva and biofilm were collected for microbiological assessment of mutans streptococci (MS) counts. Data were analyzed using the Kruskal-Wallis/Mann-Whitney U tests for clinical analysis and microbiological evaluations (p < 0.05).

Results

The survival rate of restorations was similar comparing groups I with II. Microbiological analysis showed a significant reduction in MS levels 7 days after the treatment in both saliva and biofilm of children treated with RM-GIC containing CHX (group II); however, MS counts at 3 and 6 months did not differ from the initial counts.

Conclusion

A total of 1.25% CHX improved the microbiological properties of GIC in the short term without impairing the clinical performance of ART restorations.

Clinical significance

Glass ionomer cement (GIC) containing CHX could be an alternative in ART procedures with the objective of promoting an additional antimicrobial effect, which is interesting for children with high counts of MS during the initial phase of adaptation to dental treatment.

How to cite this article

da Silva ME, de Sena MD, Colombo NH, et al. Short-term Clinical and Microbiological Performance of Resin-modified Glass Ionomer Cement Containing Chlorhexidine for Atraumatic Restorative Treatment. Int J Clin Pediatr Dent 2023;16(S-1):S27-S32.

Use of rubber dam versus cotton roll isolation on composite resin restorations' survival in primary molars: 2-year results from a non-inferiority clinical trial

BACKGROUND

This non-inferiority randomised clinical trial aimed to evaluate the survival of direct bulk fill composite resin restorations in primary molars using different methods of moisture control: rubber dam isolation (RDI-local anaesthesia and rubber dam) and cotton roll isolation (CRI-cotton roll and saliva ejector). Secondary outcomes included baseline and 2-year incremental cost, self-reported child's pain scores and patient behaviour during the restorative procedure.

METHODS

A total of 174 molars (93 children) with dentine caries lesions were randomly allocated to study groups (RDI or CRI) and restored with bulk fill composite resin by trained operators. Two blinded examiners assessed the restorations for up to 24 months. Wong-baker faces and Frankl's behaviour rating scales were used for accessing the child's pain and behaviour, respectively. The primary outcome (restoration survival) was analysed using the two-sample non-inferiority test for survival data using Cox Regression (non-inferiority/alternative hypothesis HR > 0.85; CI = 90%). Bootstrap Linear regression was used for cost analysis and logistic regression for pain and behaviour analysis (α = 5%).

RESULTS

After 2-years, 157 restorations were evaluated (drop-out = 9.7%). The survival rate was RDI = 60.4% and CRI = 54.3%. The non-inferiority hypothesis was accepted by the Cox Regression analysis (HR = 1.33; 90% CI 0.88-1.99; p = 0.036). RDI was 53% more expensive when compared to the CRI group. No differences were found between the groups regarding pain (p = 0.073) and behaviour (p = 0.788).

CONCLUSION

Cotton roll isolation proved to be non-inferior when compared to rubber dam for composite restorations longevity in primary molars. Furthermore, the latest presented the disadvantage of higher cost and longer procedure time. Clinical Significance The moisture control method does not influence the longevity of composite restorations in primary molars. Cotton roll isolation proved to be non-inferior to rubber dam isolation and is a viable option for restoring primary molars. Clinical trial registration registered NCT03733522 on 07/11/2018. The present trial was nested within another clinical trial, the CARies DEtection in Children (CARDEC-03-NCT03520309).

Pulp vitality of primary molars with deep caries treated with ART restorations: 2-year RCT

The aim of this study was to compare the pulp vitality of primary teeth with deep caries treated with two restorative techniques. The restoration survival rate was also evaluated as a secondary outcome. Children aged from 4 to 8 years with at least one deep carious lesion in molars were selected at the Ibirapuera University dental clinic. One hundred and eight deciduous molars were allocated into two groups: (1) restoration with calcium hydroxide cement lining followed by filling with high-viscosity glass ionomer cement (CHC+HVGIC) or (2) restoration with HVGIC. Pulp vitality and restoration survival were evaluated at 6, 12, and 24 months. Intent-to-treat analysis was used for pulp vitality, and survival analysis was performed with the Kaplan-Meier method (α=5%). Results: At 24 months, 86 restorations were evaluated, and 91 were evaluated at least once during the study. There was no significant difference between the restorative treatments regarding pulp vitality (CHC +HVGIC=70% and HVGIC=68.5%) (OR=1.091; CI95%=0.481-2.475). However, HVGIC (73%) restorations showed a higher survival rate than CHC+HVGIC (50%) (p=0.021). Thus, it can conclude that deep caries in primary molars should be restored with HVGIC, since the technique results in similar pulp vitality to the CHC +HVGIC, but with a higher restoration survival rate.

Stainless steel crown vs bulk fill composites for the restoration of primary molars post-pulpectomy: 1-year survival and acceptance results of a randomized clinical trial

BACKGROUND

A key factor for the success and longevity of the endodontic treatment is sealing of the cavity after restorative treatment.

AIM

The aim of this randomised clinical trial was to evaluate the 1-year survival of endodontic treatment in primary molars restored with stainless steel crowns (SSCs) and bulk fill composite resin (BF). As a secondary outcome, the acceptance of both children and parents was evaluated.

DESIGN

Ninety-one 3- to 8-year-old children with at least one primary molar requiring endodontic treatment were selected. Participants were randomized to SSC or BF and evaluated after 1, 3, 6, and 12 months. An acceptance questionnaire was completed immediately after the treatment. The primary outcome was the endodontic treatment success, evaluated in the intention-to-treat (ITT) population using the Kaplan-Meier and non-inferiority Cox regression analyses, with a non-inferiority limit of 15%. Sensitivity analysis between the success rates after 1 year was performed using Miettinen-Nurminen's method. The Mann-Whitney test was used to compare the treatment acceptance (α = 5%).

RESULTS

The survival rate after 1 year was BF = 75% and SSC = 88% (HR = 1.41; 90% CI 0.57-3.43). ITT analysis showed a success rate of BF = 86.7% and SSC = 82.6% (RR = 0.95; 0.78-1.16). The non-inferiority hypothesis between the survival of endodontic treatment could not be proved in both analyses (P > .05). The overall acceptance scores did not differ between the restorative groups (P > .05).

CONCLUSION

This study failed to show non-inferiority of BF compared with the SSC. The materials were well accepted by both children and their parents.

Giomer composite compared to glass ionomer in occlusoproximal ART restorations of primary molars: 24-month RCT

BACKGROUND

Occlusoproximal restorations of primary molars usually fail, so it is necessary to investigate new materials that may overcome this challenge. Thus, this trial aimed to evaluate the longevity of occlusoproximal ART restorations in primary molars using a glass ionomer cement - GIC (Equia Forte^® - GC Corp) and a Giomer resin composite - GCR (Beautifil Bulk Restorative^® - Shofu Inc) after 24 months.

METHODS

One hundred and eighty-two (182) children aged from 4 to 8 years were selected and randomly assigned to GIC or GCR. A paediatric dentist treated them in the school setting in Cerquilho, Brazil, and the restorations were assessed after 3, 6, 12, 18 and 24 months. The primary outcome was the restoration survival, evaluated using the Kaplan-Meier and superiority Cox regression analyses. Intention to treat (ITT) was performed as a sensitivity analysis using superiority test P value and confidence interval (CI = 95%). Independent variables included gender, age, molar, jaw, cavity volume and caries experience.

RESULTS

The restoration survival after 24 months was GIC = 58.1% and GCR = 49.1% (HR = 1.24; CI = 0.97-1.59). ITT analysis showed a success of GIC = 61.1% and GCR = 52.2% (RR = 1.17; CI = 0.91-1.52). The superiority hypothesis was not proved in both analyses (P > 0.05).

CONCLUSION

GCR does not have superior longevity than GIC in occlusoproximal ART restorations of primary molars.

The economic impact of two diagnostic strategies in the management of restorations in primary teeth: a health economic analysis plan for a trial-based economic evaluation

BACKGROUND

Different approaches have been used by dentists to base their decision. Among them, there are the aesthetical issues that may lead to more interventionist approaches. Indeed, using a more interventionist strategy (the World Dental Federation - FDI), more replacements tend to be indicated than using a minimally invasive one (based on the Caries Around Restorations and Sealants-CARS). Since the resources related to the long-term health effects of these strategies have not been explored, the economic impact of using the less-invasive strategy is still uncertain. Thus, this health economic analysis plan aims to describe methodologic approaches for conducting a trial-based economic evaluation that aims to assess whether a minimally invasive strategy is more efficient in allocating resources than the conventional strategy for managing restorations in primary teeth and extrapolating these findings to a longer time horizon.

METHODS

A trial-based economic evaluation will be conducted, including three cost-effectiveness analyses (CEA) and one cost-utility analysis (CUA). These analyses will be based on the main trial (CARDEC-03/ NCT03520309 ), in which children aged 3 to 10 were included and randomized to one of the diagnostic strategies (based on FDI or CARS). An examiner will assess children's restorations using the randomized strategy, and treatment will be recommended according to the same criteria. The time horizon for this study is 2 years, and we will adopt the societal perspective. The average costs per child for 24 months will be calculated. Three different cost-effectiveness analyses (CEA) will be performed. For CEAs, the effects will be the number of operative interventions (primary CEA analysis), the time to these new interventions, the percentage of patients who did not need new interventions in the follow-up, and changes in children's oral health-related quality of life (secondary analyses). For CUA, the effect will be tooth-related quality-adjusted life years (QALYs). Intention-to-treat analyses will be conducted. Finally, we will assess the difference when using the minimally invasive strategy for each health effect (∆effect) compared to the conventional strategy (based on FDI) as the reference strategy. The same will be calculated for related costs (∆cost). The discount rate of 5% will be applied for costs and effects. We will perform deterministic and probabilistic sensitivity analyses to handle uncertainties. The net benefit will be calculated, and acceptability curves plotted using different willingness-to-pay thresholds. Using Markov models, a longer-term economic evaluation will be carried out with trial results extrapolated over a primary tooth lifetime horizon.

DISCUSSION

The main trial is ongoing, and data collection is still not finished. Therefore, economic evaluation has not commenced. We hypothesize that conventional strategy will be associated with more need for replacements of restorations in primary molars. These replacements may lead to more reinterventions, leading to higher costs after 2 years. The health effects will be a crucial aspect to take into account when deciding whether the minimally invasive strategy will be more efficient in allocating resources than the conventional strategy when considering the management of restorations in primary teeth. Finally, patients/parents preferences and consequent utility values may also influence this final conclusion about the economic aspects of implementing the minimally invasive approach for managing restorations in clinical practice. Therefore, these trial-based economic evaluations may bring actual evidence of the economic impact of such interventions.

TRIAL REGISTRATION

NCT03520309 . Registered May 9, 2018. Economic evaluations (the focus of this plan) are not initiated at the moment.

Survival rate of primary molar restorations is not influenced by hand mixed or encapsulated GIC: 24 months RCT

BACKGROUND

Glass ionomer cements (GIC) have been considered the top option to restore primary teeth by dentists. The most common supply forms are hand mixed and encapsulated GIC. There is a lack of information about the impact of different GIC supply forms on restoration survival.

METHODS

This randomized clinical trial compared the survival rate of occlusal and occlusoproximal restorations in primary molars using two glass ionomer cements versions: hand-mixed (H/M) and encapsulated (ENC) after 24 months. Children aged 3-10 years who presented dentin caries lesions in primary molars were selected at School of Dentistry, University of São Paulo, Brazil. They were randomly assigned to groups: H /M (Fuji IX^®, GC Europe) or ENC (Equia Fill^®, GC Europe). The occurrence of restoration failure was evaluated by two blinded and calibrated examiners. The analyses were performed in Stata 13 (StataCorp, USA). To evaluate the primary outcome (restoration survival), we  performed a survival analysis. Additionally an intention to treat (ITT) analysis were done at 24 months of follow-up. Cox Regression with shared frailty was performed to assess association between restoration failure and independent variables (α = 5%).

RESULTS

A total of 324 restorations were performed in 145 children. The survival for H/M group was 58.2% and 60.1% for ENC, with no difference (p = 0.738). Occlusoproximal restorations had lower survival rate when compared to occlusal ones (HR = 3.83; p < 0.001).

CONCLUSIONS

The survival rate in primary molars is not influenced by the different supply forms of GIC. Also, occlusoproximal restorations present reduced performances when compared to occlusal cavities.

TRIAL REGISTRATION

This randomized clinical trial was registered on ClinicalTrials.Gov on 10/15/2014 under protocol (NCT02274142).

Sedation versus protective stabilization for dental treatment of children with caries and challenging behavior at the dentist (CHOOSE): a study protocol for a non-randomized clinical trial

BACKGROUND

There is a lack of evidence on the effectiveness of moderate sedation in pediatric dentistry, compared to protective stabilization, which remains routinely used in Brazil despite moral questions. This prospective non-randomized clinical trial's objective is to evaluate the effectiveness of moderate sedation, compared to the protective stabilization, in the dental care of children with dental behavior management problems.

METHODS

Participants will be 152 children under seven years of age with early childhood caries (ECC) who need specialized dental treatment due to a history of challenging behavior during dental care. The interventions to be compared are moderate sedation with oral administration of ketamine and midazolam and protective stabilization. The primary endpoint will be the child's behavior during treatment assessed using the Ohio State University Behavioral Rating Scale (OSUBRS). The secondary outcomes are (A) child's - behavior according to the visual analogue scale, anxiety, pain, and physiological stress; (B) parent's - satisfaction and anxiety; (C) family and child - impact on oral health-related quality of life (OHRQoL); (D) dentist's - satisfaction and stress; (E) procedure - adverse events of the intervention and dental treatment longevity. A cost-effectiveness analysis will be performed from the perspective of the Brazilian Unified Health System (SUS).

DISCUSSION

Considering the primary outcome, this study hypothesis is that sedated children have better behavior during dental treatment than children whose behavior was managed by protective stabilization without sedation. Additionally, at the end of 12 months, we expect to identify participants' reported outcomes and objective measures related to dental behavior in early childhood. Trial registration Clinicaltrials.gov registration NCT04119180 on October 8th, 2019. https://clinicaltrials.gov/ct2/show/NCT04119180.

Negligible therapeutic impact, false-positives, overdiagnosis and lead-time are the reasons why radiographs bring more harm than benefits in the caries diagnosis of preschool children

Background

To evaluate the clinical course and interventions required during two years of follow-up of dental surfaces of deciduous molars diagnosed, and consequently treated, by two different strategies: diagnosis made by clinical examination alone or associated with radiographs.

Methods

This is a secondary analysis of a two-arm randomized clinical trial with parallel groups related to the diagnostic strategy for caries detection in preschool children. 216 children (3–6 years old) were followed-up for two years. All dental surfaces were diagnosed by visual inspection and later, through radiographic assessment. Baseline treatment was made in accordance with the results obtained by visual inspection performed alone or combined with radiographic method, considering the allocated group. Dental surfaces with no restoration needs, or those restored at the beginning of the study were followed-up for two years. The treatment decision was made according to the allocated group. The outcome was the occurrence of failure (a new caries lesion or a restoration replacement) during the follow-up.

Results

4383 proximal and occlusal surfaces of deciduous molars in 216 preschool children were diagnosed and treated according to the abovementioned diagnostic strategies and followed-up for 24 months. The assessment of radiographs made change the initial decision reached by visual inspection in about 30% of the surfaces when all types of interventions were considered. However, most disagreements occurred for initial lesions, where radiographs tended to underestimate them. Discordances between methods occurred in less than 5% of all surfaces when considered lesions requiring operative treatment. For discrepancy cases, the placed interventions guided by following the radiographic results did not present less failures against those made following only visual inspection. As a matter of fact, the use of radiographs in the diagnostic strategy for caries detection in children brought more harms than benefits due to the occurrence of false-positives, overdiagnosis and lead-time bias.

Conclusions

Simultaneous association of visual inspection and radiographic assessment for caries detection in preschool children causes more harms than benefits, and therefore, visual inspection should be conducted alone in the regular clinical practice.

Trial registration Clinicaltrials.gov platform: NCT02078453, registered on 5th March 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01528-w.

Factors affecting success rate of atraumatic restorative treatment (ART) restorations in children: A systematic review and meta-analysis

OBJECTIVES

Aim of this systematic review was to summarize the factors that affect the success rate of atraumatic restorative treatment (ART) restorations in children.

DATA/SOURCES

Two independent reviewers conducted a literature search in the databases PubMed, Medline and Web of Science until October 2019 with no initial time limit. Articles reporting on clinical outcomes of ART restorations placed in children were included.

STUDY SELECTION

A total of 67 articles were included in this review reporting on clinical outcomes of ART restorations placed in children in 47 studies. The overall estimated success rate and 95 % confidence interval (CI) of ART restorations were 0.71 (0.65-0.77) and 0.67 (0.56-0.78) at the 12-month and the 24-month follow-up, respectively. Operator was one of the significant factors associated with the success rate of ART restorations. ART restorations placed by dental students/therapists had a significantly lower success rate compared with those placed by dentists. Besides, type of restoration (single-surface vs. multiple-surface restoration) was also associated with the success rate of ART restorations. Other factors including dentition, restorative material, clinical setting, and moisture control method had no significant influence on the success rate of ART restorations in children.

CONCLUSION

It is concluded that ART approach can be used to manage cavitated caries lesions in children. Operator and type of restoration are significant factors influencing the success rate of ART restorations.

CLINICAL SIGNIFICANCE

This study provides valuable information on the factors that affect success rate of ART restorations in children, which helps clinicians to make informed decisions on provision of ART restorations in children.

The effect of two clinical criteria in the assessment of caries lesions around restorations in children (CARDEC-03): study protocol for a diagnostic randomized clinical trial

Introduction: The detection of caries lesions around restoration can be challenging. Therefore, the use of some criteria has been proposed in order to give more objectivity to the diagnosis process. Two of them are the International Dental Federation (FDI) and the Caries Associated with Restorations and Sealants (CARS) criteria. Both methods have a different approach to caries, and it is not possible to know which one of them is the best to use in clinical practice to assess restorations in children. Thus, the present protocol aims to evaluate the effect of the use of the FDI and CARS criteria in the assessment of caries lesions around restorations in primary teeth on outcomes related to oral health in children and costs resulting from the assessments.

Methods and analysis: A total of 626 restorations of children from three to 10 years were randomly assessed and are being treated following the FDI criteria (FDI group) or CARS criteria (CARS group). Participants will be followed-up after six, 12, 18, and 24 months. The primary outcome will be the need for a new intervention in the evaluated restorations. This outcome consists of several components, and each of these events will be analyzed separately as secondary outcomes. The changes in children’s oral health-related quality of life and the cost of the restoration dental treatments will also be analyzed as secondary outcomes. The methods will be compared using the Cox regression model with shared frailty. A significance level of 5% will be adopted for all statistical analyses.

Discussion: This will be the first randomized clinical study carried out regarding the detection of caries lesions around restorations in primary teeth.

Trial registration: The study underwent registration in Clinicaltrials.gov ( NCT03520309) on 9 May 2018.

Impact of different restorative treatments for deep caries lesion in primary teeth (CEPECO 1) - study protocol for a noninferiority randomized clinical trial

Background

Due to the lack of evidence to determine the best treatment for deep cavitated caries lesions in primary molars, the search for an effective restorative technique, which results in a minimal discomfort to patients, and reduce the time needed for the treatment, becomes relevant. The objective of this randomized clinical trial was to evaluate if high-viscosity glass ionomer cement (HVGIC) restorations is noninferior to restoration with calcium hydroxide cement associated with HVGIC for treatment of deep lesions in primary molars, as well as the impact of the treatments on cost and discomfort of the patient.

Methods

A non-inferiority randomized clinical trial with two parallels arms (1:1) will be conducted. Children with 4 to 8 years will be selected at Clinic of Pediatric Dentistry at Ibirapuera University. 108 teeth will be randomized into two groups: (1) Calcium hydroxide cement associated with HVGIC and (2) HVGIC restoration. Primary outcome will be considered the pulp vitality and to be evaluated after 6, 12, 18 and 24 months by two calibrated examiners. Survival of restorations will also be evaluated in the equal intervals. The duration of dentals treatment and the cost of all materials used will be considered for estimating of cost-efficacy of each treatment. Individual discomfort will be measured after each dental procedure using the Wong-Baker’s Facial Scale. For the primary outcome, Kaplan-Meier survival and the long-rank test will be used to comparison between the groups. Cox regression will be performed to assess the influence of variables on the outcome. For all analyzes, the significance level is set at 5%.

Discussion

Based on the philosophy of ART, our hypothesis is that the HVGIC restoration is a possible approach to restore the deep caries lesion with pulp vitality without the use of rubber dam and anesthesia.

Trial registration

Clinicaltrials.gov registration NCT02903979. Registered on June 9th 2016.

Electronic supplementary material

The online version of this article (10.1186/s12903-018-0703-3) contains supplementary material, which is available to authorized users.

Patient-reported outcomes associated with different restorative techniques in pediatric dentistry: A systematic review and MTC meta-analysis

BACKGROUND

Despite the increasing number of studies evaluating patient reported outcome measures (PROs), there is no clearness regarding which restorative treatment offers major benefits based on the pediatric patient perspective.

AIM

To compare different restorative techniques in pediatric dentistry regarding patient-reported outcomes.

DESIGN

Literature searching was carried out on prospective studies indexed in PubMed, Scopus and OpenGrey. A Mixed Treatment Comparisons (MTC) meta-analysis was undertaken considering the results from reviewed studies. Anxiety, pain and quality of life were extracted as mean with standard deviation, percentage of pain, and mean difference of scores with standard deviation, respectively. For direct comparisons, data were combined using a random-effect model. Heterogeneity was assessed with the I2 statistic. For indirect comparisons, fixed and random effects were chosen through comparison of competing models based on the Deviance Information Criteria (DIC). The expected efficacy ranking based on the posterior probabilities of all treatment rankings was also calculated.

RESULTS

An initial search resulted in 4,322 articles, of which 17 were finally selected. Due to unavailability of data, only pain, anxiety and oral health related quality of life (OHRQoL) were statistically analyzed. The difference in means (95% CI) of anxiety between treatments using only hand instruments with or without chemomechanical agents were -5.35 (-6.42 to -4.20) and -5.79 (-7.77 to -3.79) respectively when compared to conventional treatment using rotary instruments and/or local anesthesia. Regarding pain, there was a trend for treatments without rotary instruments and local anesthesia to be less frequently reported as painful. No statistical difference was found intragroup nor among treatments for OHRQoL.

CONCLUSIONS

Anxiety and pain are directly related with more invasive restorative treatments. On the other hand, quality of life is not improved regardless of the restorative technique used. Further well-designed prospective studies regarding PROs in children are still necessary.

Survival percentages of atraumatic restorative treatment (ART) restorations and sealants in posterior teeth: an updated systematic review and meta-analysis

OBJECTIVE

The aim of the present study is to update the results of two previous meta-analyses, published in 2006 and 2012, on the survival percentages of atraumatic restorative treatment (ART) restorations and ART sealants. The current meta-analysis includes Chinese publications not investigated before.

MATERIALS AND METHODS

Until February 2017, six databases were interrogated (two English, one Portuguese, one Spanish and two Chinese). Using six exclusion criteria, a group of six independent reviewers selected 43 publications from a total of 1958 potentially relevant studies retrieved. Confidence intervals and/or standard errors were calculated and the heterogeneity variance of the survival rates was estimated.

RESULTS

The survival percentages and standard errors of single-surface and multiple-surface ART restorations in primary posterior teeth over the first 2 years were 94.3% (± 1.5) and 65.4% (± 3.9), respectively; for single-surface ART restorations in permanent posterior teeth over the first 3 years, they were 87.1% (± 3.2); and for multiple-surface ART restorations in permanent posterior teeth over the first 5 years, they were 77% (± 9.0). The mean annual dentine-carious-lesion-failure percentages in previously sealed pits and fissures using ART sealants in permanent posterior teeth over the first 3 and 5 years were 0.9 and 1.9%, respectively.

CONCLUSIONS

ART single-surface restorations presented high survival percentages in both primary and permanent posterior teeth, whilst ART multiple-surface restorations presented lower survival percentages. ART sealants presented a high-caries-preventive effect.

CLINICAL RELEVANCE

ART is an effective evidence-based option for treating and preventing carious lesions in primary and permanent posterior teeth.

Atraumatic restorative treatment versus conventional restorative treatment for managing dental caries

BACKGROUND

Dental caries is a sugar-dependent disease that damages tooth structure and, due to loss of mineral components, may eventually lead to cavitation. Dental caries is the most prevalent disease worldwide and is considered the most important burden of oral health. Conventional treatment methods (drill and fill) involve the use of rotary burs under local anaesthesia. The need for an electricity supply, expensive handpieces and highly trained dental health personnel may limit access to dental treatment, especially in underdeveloped regions.To overcome the limitations of conventional restorative treatment, the Atraumatic Restorative Treatment (ART) was developed, mainly for treating caries in children living in under-served areas of the world where resources and facilities such as electricity and trained manpower are limited. ART is a minimally invasive approach which involves removal of decayed tissue using hand instruments alone, usually without use of anaesthesia and electrically driven equipment, and restoration of the dental cavity with an adhesive material (glass ionomer cement (GIC), composite resins, resin-modified glass-ionomer cement (RM-GICs) and compomers).

OBJECTIVES

To assess the effects of Atraumatic Restorative Treatment (ART) compared with conventional treatment for managing dental caries lesions in the primary and permanent teeth of children and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 22 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 1), MEDLINE Ovid (1946 to 22 February 2017), Embase Ovid (1980 to 22 February 2017), LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 22 February 2017) and BBO BIREME Virtual Health Library (Bibliografia Brasileira de Odontologia; 1986 to 22 February 2017). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with at least six months' follow-up that compared the effects of ART with a conventional restorative approach using the same or different restorative dental materials to treat caries lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data from included studies and assessed the risk of bias in those studies. We used standard methodological procedures expected by Cochrane to evaluate risk of bias and synthesise data. Where pooling was appropriate we conducted meta-analyses using the random-effects model. We assessed the quality of the evidence using GRADE criteria.

MAIN RESULTS

We included a total of 15 eligible studies randomising 3760 participants in this review. The age of participants across the studies ranged from 3 to 101 years, with a mean of 25.42 years. 48% of participants were male. All included studies were published between 2002 and 2016. Two of the 15 studies declared that the financial support was from companies that manufacture restorative material. Five studies were individually randomised parallel-group studies; six were cluster-randomised parallel-group studies; and four were randomised studies that used a split-mouth design. Eleven studies evaluated the effects of ART on primary teeth only, and four on permanent teeth. The follow-up period of the included studies ranged from 6 months to 36 months. We judged all studies to be at high risk of bias.For the main comparison of ART compared to conventional treatment using the same material: all but two studies used high-viscosity glass ionomer (H-GIC) as the restorative material; one study used a composite material; and one study used resin-modified glass ionomer cement (RM-GIC)).Compared to conventional treatment using H-GIC, ART may increase the risk of restoration failure in the primary dentition, over a follow-up period from 12 to 24 months (OR 1.60, 95% CI 1.13 to 2.27, five studies; 643 participants analysed; low-quality evidence). Our confidence in this effect estimate is limited due to serious concerns over risk of performance and attrition bias. For this comparison, ART may reduce pain during procedure compared with conventional treatment (MD -0.65, 95% CI -1.38 to 0.07; 40 participants analysed; low-quality evidence)Comparisons of ART to conventional treatment using composite or RM-GIC were downgraded to very low quality due to indirectness, imprecision and high risk of performance and attrition bias. Given the very low quality of the evidence from single studies, we are uncertain about the restoration failure of ART compared with conventional treatment using composite over a 24-month follow-up period (OR 1.11, 95% CI 0.54 to 2.29; one study; 57 participants) and ART using RM-GIC in the permanent teeth of older adults with root caries lesions over a six-month follow-up period (OR 2.71, 95% CI 0.94 to 7.81; one study; 64 participants).No studies reported on adverse events or costs.

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that ART using H-GIC may have a higher risk of restoration failure than conventional treatment for caries lesions in primary teeth. The effects of ART using composite and RM-GIC are uncertain due to the very low quality of the evidence and we cannot rely on the findings. Most studies evaluated the effects of ART on the primary dentition.Well-designed RCTs are required that report on restoration failure at clinically meaningful time points, as well as participant-reported outcomes such as pain and discomfort. Due to the potential confounding effects from the use of different dental materials, a robust body of evidence on the effects of ART compared with conventional treatment using the same restoration material is necessary. We identified four ongoing trials that could provide further insights into this area.

In vitro and in vivo evaluations of glass-ionomer cement containing chlorhexidine for Atraumatic Restorative Treatment

Objectives:

Addition of chlorhexidine has enhanced the antimicrobial effect of glass ionomer cement (GIC) indicated to Atraumatic Restorative Treatment (ART); however, the impact of this mixture on the properties of these materials and on the longevity of restorations must be investigated. The aim of this study was to evaluate the effects of incorporating chlorhexidine (CHX) in the in vitro biological and chemical-mechanical properties of GIC and in vivo clinical/ microbiological follow-up of the ART with GIC containing or not CHX.

Material and Methods:

For in vitro studies, groups were divided into GIC, GIC with 1.25% CHX, and GIC with 2.5% CHX. Antimicrobial activity of GIC was analyzed using agar diffusion and anti-biofilm assays. Cytotoxic effects, compressive tensile strength, microhardness and fluoride (F) release were also evaluated. A randomized controlled trial was conducted on 36 children that received ART either with GIC or GIC with CHX. Saliva and biofilm were collected for mutans streptococci (MS) counts and the survival rate of restorations was checked after 7 days, 3 months and one year after ART. ANOVA/Tukey or Kruskal-Wallis/ Mann-Whitney tests were performed for in vitro tests and in vivo microbiological analysis. The Kaplan-Meier method and Log rank tests were applied to estimate survival percentages of restorations (p<0.05).

Results:

Incorporation of 1.25% and 2.5% CHX improved the antimicrobial/anti-biofilm activity of GIC, without affecting F release and mechanical characteristics, but 2.5% CHX was cytotoxic. Survival rate of restorations using GIC with 1.25% CHX was similar to GIC. A significant reduction of MS levels was observed for KM+CHX group in children saliva and biofilm 7 days after treatment.

Conclusions:

The incorporation of 1.25% CHX increased the in vitro antimicrobial activity, without changing chemical-mechanical properties of GIC and odontoblast-like cell viability. This combination improved the in vivo short-term microbiological effect without affecting clinical performance of ART restorations.

Efficacy of conventional treatment with composite resin and atraumatic restorative treatment in posterior primary teeth: study protocol for a randomised controlled trial

INTRODUCTION

Despite the widespread acceptance of conventional treatment using composite resin in primary teeth, there is limited evidence that this approach is the best option in paediatric clinics. Atraumatic restorative treatment (ART) using high-viscosity glass ionomer cement has gradually become more popular because it performs well in clinical studies, is easy to handle and is patient friendly. Therefore, the aim of this randomised clinical trial study is to compare the restoration longevity of conventional treatment using composite resin with that of ART in posterior primary teeth. As secondary outcomes, cost-efficacy and patient self-reported discomfort will also be tested.

METHODS AND ANALYSIS

Children aged 3-6 years presenting with at least one occlusal and/or occlusal-proximal cavity will be randomly assigned to one of two groups according to the dental treatment: ART (experimental group) or composite resin restoration (control group). The dental treatment will be performed at a dental care trailer located in an educational complex in Barueri/SP, Brazil. The unit of randomisation will be the child. A sample size of 240 teeth with occlusal cavities and 188 teeth with occlusal-proximal cavities has been calculated. The primary outcome will be restoration longevity, which will be clinically assessed after 6, 12, 18 and 24 months by two examiners. The duration of the dental treatment and the cost of all materials used will be considered when estimating the cost-efficacy of each treatment. Individual discomfort will be measured after each dental procedure using the Facial Scale of Wong-Baker.

ETHICS AND DISSEMINATION

This clinical trial was approved by the local ethics committee from the Faculty of Dentistry of the University of São Paulo (registration no. 1.556.018). Participants will be included after their legal guardians have signed an informed consent form containing detailed information about the research.

TRIAL REGISTRATION NUMBER

www.clinicaltrials.gov, NCT02562456; Pre-results.

Effectiveness of conventional treatment using bulk-fill composite resin versus Atraumatic Restorative Treatments in primary and permanent dentition: a pragmatic randomized clinical trial

Background

Clinical studies are being conducted in less strict conditions in order to establish an adequate scientific basis for decision making. The aim of this pragmatic randomized clinical trial is to evaluate the effectiveness of single and multiple-surfaces restorations performed following the Atraumatic Restorative Treatment (ART) premises compared with Conventional Treatment (CT) using bulk fill composite restorations in primary and permanent teeth.

Methods/design

A total of 1,214 5-to-13 year-old children with at least one single or multiple-surface dentin caries lesion in primary or permanent molars will be selected in public schools of Barueri-SP, Brazil. The participants will be randomly assigned into 2 groups: CT (caries removal with bur and restoration performed with Scotchbond™ Universal Adhesive system associated with Filtek Bulk Fill – 3 M/ESPE) and ART (Caries removal with hand instruments and restoration with high viscosity glass ionomer cement Ketac Molar Easy Mix – 3 M/ESPE). Ten untrained dentists will perform the treatment in in dental offices located at public schools. The restorations will be evaluated after 6, 12 and 24 months by an independent trained and calibrated examiner. The restoration and tooth survival, the cost-effectiveness analysis between the two groups and the operators’ preferences regarding the techniques will be also evaluated. Kaplan-Meier survival analysis and log-rank test will be applied for the restoration and tooth survival. All the average event rates in the two groups will be modelled and compared with a Cox proportional hazard shared frailty model since there is an operator-cluster effect. The significance level for all analyses will be 5 %.

Discussion

Our hypothesis is that despite similar expected effectiveness between ART using high viscosity GIC and conventional treatment using bulk fill composite resin when treating single or multiple-surface in posterior primary and permanent teeth, ART will present superior cost-effectiveness. The results of this trial will support decision-making by clinicians and policy makers.

Trial registration

NCT02568917. Registered on May 10th 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-016-0260-6) contains supplementary material, which is available to authorized users.

Bilayer technique and nano-filled coating increase success of approximal ART restorations: a randomized clinical trial

BACKGROUND

The high-viscosity consistency of glass ionomer cement (GIC) may lead to its incorrect adaptation into the cavity and therefore to restoration failure.

AIM

To compare two different insertion techniques for GIC in approximal atraumatic restorative treatment (ART) restorations and two different surface protection materials.

DESIGN

Approximal caries lesion in primary molars from 208 schoolchildren was randomly assigned into four groups: G1, conventional GIC insertion protected with petroleum jelly (PJ); G2, bilayer technique protected with PJ; G3 conventional GIC insertion protected with nano-filled particles coating for GIC (NPC); G4, bilayer technique protected with NPC. Restorations were evaluated after 1, 6, 12, 18, 24, and 36 months. Kaplan-Meier survival analysis and log-rank test were performed. Cox regression analysis (α = 5%) was used to verify the influence of clinical factors.

RESULTS

Restoration survival was 52.8%. Log-rank test indicated a better survival of the bilayer technique restorations, compared to conventional restorations (P = 0.005), whereas the coated conventional restorations presented higher survival than the uncoated ones (P = 0.035). Cox regression analysis showed no influence of any clinical tested variables.

CONCLUSION

The survival rate of the approximal ART restorations is positively influenced by the bilayer technique, and the application of nano-filled coating increases the longevity of the conventional approximal ART restorations.

One-year follow-up of Atraumatic Restorative Treatment(ART) for dental caries in children undergoing oncohematological treatment: a pragmatic trial

Background

The oral condition in children undergoing oncohematological treatment can have a negative impact on the course of disease. Little is known about survival of tooth restorations in these patients. The aim of this study was to evaluate the longevity of restorations and sealants performed by Atraumatic Restoration Treatment (ART) in patients undergoing oncohematological treatment.

Methods

ART single surface restorations and sealants were performed in the experimental group (E), which comprised children (2–13 years old) undergoing oncohematological treatment, and in the control group (C), in which patients did not undergo such treatment. The same examiner evaluated the ART at 1, 3, 6 and 12 months after preparation, using the same criteria for restorations and sealants. ART was successful if the sealant or restoration did not need a repair in the follow-up assessment. Descriptive, bivariate and Cox’s proportional hazard analyses were performed at a significance level of 5 %.

Results

The two groups, one including 24 children (E) and the other 14 children (C), received 101 and 52 ART procedures, respectively. The success rates were 95.0 % (E) and 100 % (C) at 1 month (P = 0.233); 81.2 % (E) and 92.3 % (C) at 3 months (P = 0.009); 72.2 % (E) and 80.8 % (C) at 6 months (P = 0.050) and 48.5 % (E) and 73.1 % (C) at 12 months (P = 0.001). The final Cox’s regression model for occurrence of ART failure needing repair did not show differences between groups (E: OR = 1.6, 95 % CI 0.8–2.9); primary teeth had a shorter survival than permanent teeth (OR = 2.1, 95 % CI 1.2–3.7).

Conclusions

Oncohematological treatment did not interfere with the longevity of ART restorations and sealants, which suggests the potential use of this technique in children undergoing chemotherapy.

Trial registration

Brazilian Clinical Trials Registry (REBEC) RBR-2c3c52. Registered 5 June 2014. http://www.ensaiosclinicos.gov.br/rg/RBR-2c3c52/

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-015-0110-y) contains supplementary material, which is available to authorized users.

The effects of ambient temperature and mixing time of glass ionomer cement material on the survival rate of proximal ART restorations in primary molars

Objective:

Temperature fluctuations and material mixing times are likely to affect the consistency and integrity of the material mixture, and hence the restoration made out of it. The purpose of the present study was to determine the influence of the ambient temperature and the mixing time of glass ionomer cement (GIC) restorative material on the survival rate of proximal atraumatic restorative treatment (ART) restorations placed in primary molars.

Materials and Methods:

A total of 804 restorations were placed in the primary molars of 6-8-year-olds using the ART approach. The restorations were then followed for a period of 2 years and evaluated at given intervals. The data collected were analyzed using SPSS computer statistical program, and the results tested and compared using the Chi-square, Kaplan Meier survival analysis and Cox Proportional hazard statistical tests.

Results:

The cumulative survival rate of the restorations dropped from the initial 94.4% to 30.8% at the end of 2 years. The higher survival rate of the restorations was associated with the experienced operators and assistants when using the rubber dam isolation method. However, there was no statistically significant difference in the survival rate of the restorations when related to the room temperature and the mixing time of the GIC materials used in spite of the variations in the temperature recoded and the methods used in mixing the materials.

Conclusion:

The ambient temperature and mixing time of GIC did not have a significant effect on the survival of the proximal ART restorations.

The effect of GIC-brand on the survival rate of proximal-ART restorations

BACKGROUND

Laboratory studies show diverse behaviour of different brands of glass-ionomer cements (GIC).

AIM

This study investigated the clinical performance [survival rate (SR)] of three GIC brands applied to proximal atraumatic restorative treatment (ART) restorations. Additionally, the SR of the tooth was evaluated.

DESIGN

Proximal cavities of 262 primary molars were restored. The patients had been randomly allocated to two operators and three GIC brands: Fuji IX, Hi-Dense, and Maxxion R. Restorations were evaluated after 1, 6, 12, 18, 24, 30, and 36 months. Failed restorations were, if possible, repaired or replaced. Linear regression analyses were used to evaluate the effect of GIC brand, operator, and surface of restoration. Kaplan-Meier survival analysis and log-rank test were performed for both restoration survival and tooth survival (α = 5%).

RESULTS

After 3 years, 82.4% of the restorations were evaluated. The SR of the restorations was 24.4%, and there was no difference among GIC brands (log-rank test, P = 0.6). In the first 18 months, a significant operator effect and significantly higher failures in distal surfaces were found. The SR of the tooth was 81.7%.

CONCLUSIONS

The SR of proximal ART restorations was relatively low when compared with the SR of the tooth. There are no differences in the performance among the GIC brands used in the study.

A preliminary clinical trial using flowable glass-ionomer cement as a liner in proximal-ART restorations: the operator effect

Objectives: This in vivo study was carried out to assess the influence of the operator experience on the survival rate of proximal-ART restorations using a two-layer technique to insert the glass-ionomer cement (GIC). Study Design: Forty five proximal cavities in primary molars were restored in a school setting according to the ART technique. The cavities were restored by two operators with Ketac Molar Easymix, and received a flowable layer of GIC prior to a second GIC layer with a regular consistency. The operators had different clinical experiences with ART (no experience or two years of experience), but both completed a one-week training to perform the restorations and the GIC mixing in this study. Results: After a 12-month follow-up, 74% of the restorations survived; the main reason for failure was bulk fracture or total loss of the restoration.There was no operator influence (log-rank test p=0.2) Conclusion: The results encourage future well designed controlled clinical trials using the two-layer technique for insertion of GIC in proximal-ART restorations, after training the operators.

Key words:Atraumatic Restorative Treatment (ART), Glass-ionomer, proximal restorations.

Survival rate of approximal-ART restorations using a two-layer technique for glass ionomer insertion

OBJECTIVE

Good survival rates (SR) have been reported for occlusal-atraumatic restorative treatment (ART) restorations but not for approximal-ART restorations. The high-viscosity consistency of the glass ionomer cement (GIC) may lead to its incorrect adaptation into the cavity and thus to failure of the restoration. Because the use of a flowable GIC layer seemed to improve its adaptation in approximal restorations in vitro, we evaluated whether the use of an intermediate flowable GIC layer would improve the SR of approximal-ART restorations.

METHODS

A total of 208 children (6-7 years old) with at least one occluso-proximal carious lesion in a primary molar were selected and randomly allocated to two groups: G1, conventional technique, one-layer GIC (powder/liquid ratio 1:1); and G2, two-layer technique, consisting of a first layer of GIC with a flowable consistency (powder/liquid ratio 1:2) and a second layer of a regular consistency. Restorations were made by final-year students and evaluated after 1, 6, 12 and 18 months. Restoration survival was evaluated using Kaplan-Meier survival and logrank test. Poisson regression analyses (α = 5) were used to verify the influence of factors such as insertion technique, restoration surface and operators.

RESULTS

The overall SR of the restorations after 18 months was 68 %. There was no difference in SR between the techniques, neither did the other factors influence the SR.

CONCLUSIONS

Over 18 months, the use of an intermediate flowable GIC layer in approximal-ART restorations does not improve the restoration survival.

CLINICAL RELEVANCE

This study suggests that the two-layer technique is not the answer for increasing approximal-ART restoration longevity.

Effects of oral hygiene, residual caries and cervical Marginal-gaps on the survival of proximal atraumatic restorative treatment approach restorations

Background:

Although Atraumatic restorative treatment (ART) approach has been in existence for a while, the reasons for the poor performance of multisurface ART restorations are not very clear.

Aim:

The aim of this study is to investigate the effects of oral hygiene, residual caries and cervical marginal-gaps on survival of proximal ART restorations.

Settings:

Two rural divisions in Kenya were selected for the study.

Design:

A randomized clinical trial.

Material and Methods:

The 804 children in the study had their baseline- and 2-year dental plaque levels documented. Each child received one proximal restoration in a primary molar using ART approach, together with trained and pre-tested operators/assistants, three glass ionomer cements (GIC)-brands and two tooth-isolation methods. The restorations were clinically evaluated soon after placement and after 2 years. Post-restorative bite-wing radiographs taken soon after restoration were also evaluated.

Statistical analysis:

Statistical Package for Social Sciences (SPSS) version 14 computer programme was used and results tested using Pearson's correlation, Cox Proportional Hazards regression analysis and Multiple Logistic regression models tests.

Results:

At baseline and after 2 years, the mean cumulative survival and plaque index changed from 94.4% to 30.8% and 2.34 (Standard Deviation, or SD of 0.46) to 1.92 (SD 2.1) respectively, with higher plaque indices associated with higher restoration failures. Of the 507 radiographs evaluated, 48 (9.5%), 63 (12.4%) and 9 (1.8%) restorations had residual caries (RC), cervical marginal-gaps (CMG) and both RC/CMG respectively. Survival of the restorations with RC/CMG was significantly lower (p = 0.003) compared to those with RC or without RC.

Conclusion:

Low survival of proximal restorations in the study was associated with the presence of cervical marginal-gaps.

A comparative evaluation of DIAGNOdent and caries detector dye in detection of residual caries in prepared cavities

AIM

The objective of this study was to determine the association between DIAGNOdent laser and caries detector dye in detection of the remaining caries in restorative cavities.

MATERIALS AND METHODS

The sample consisted of 100 cavities prepared in patients referring to the Department of Restorative Dentistry of Mashhad Dental School. After confirming caries absence by tactile examination, the presence of any residual caries was determined by a laser fluorescence (LF) device (DIAGNOdent Pen) and then by caries detector dye. The data were analyzed through McNemar test.

RESULTS

When the cut off value was considered as ≥13, both DIAGNOdent Pen and caries detector dye found 54 cavities as without caries and 12 cavities as carious. There were 32 teeth diagnosed as decayed only by the dye and two cases that were diagnosed as having residual caries only by the DIAGNOdent. The McNemar test revealed a significant difference in the diagnosis of residual caries between the two methods (p < 0.05), as well as significant differences between each method and tactile examination (p < 0.05). When the cut off value was set at ≥25, no significant difference was found between laser fluorescence and tactile examination in residual caries detection (p > 0.05).

CONCLUSION

Both DIAGNOdent Pen and caries detector dye can be considered as adjuncts for detecting residual caries in prepared cavities. However, the use of laser fluorescence device can provide results that are more consistent with tactile examination, while relying on caries detector dye may result in excessive removal of tooth tissue, and thus increase the risk of pulpal exposure.

CLINICAL SIGNIFICANCE

Incomparision with caries detector dye, Residual caries detection by DIAGNOdent Pen is more consistent with tactile examination.

Survival of atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis

The purpose of this study is to perform a systematic investigation plus meta-analysis into survival of atraumatic restorative treatment (ART) sealants and restorations using high-viscosity glass ionomers and to compare the results with those from the 2005 ART meta-analysis. Until February 2010, four databases were searched. Two hundred four publications were found, and 66 reported on ART restorations or sealant survival. Based on five exclusion criteria, two independent reviewers selected the 29 publications that accounted for the meta-analysis. Confidence intervals (CI) and or standard errors were calculated and the heterogeneity variance of the survival rates was estimated. Location (school/clinic) was an independent variable. The survival rates of single-surface and multiple-surface ART restorations in primary teeth over the first 2 years were 93% (CI, 91-94%) and 62% (CI, 51-73%), respectively; for single-surface ART restorations in permanent teeth over the first 3 and 5 years it was 85% (CI, 77-91%) and 80% (CI, 76-83%), respectively and for multiple-surface ART restorations in permanent teeth over 1 year it was 86% (CI, 59-98%). The mean annual dentine lesion incidence rate, in pits and fissures previously sealed using ART, over the first 3 years was 1%. No location effect and no differences between the 2005 and 2010 survival rates of ART restorations and sealants were observed. The short-term survival rates of single-surface ART restorations in primary and permanent teeth, and the caries-preventive effect of ART sealants were high.

CLINICAL RELEVANCE

ART can safely be used in single-surface cavities in both primary and permanent teeth. ART sealants have a high caries preventive effect.

Short communication: Influence of different isolation methods on the survival of proximal ART restorations in primary molars after two years

AIM

This was to evaluate the influence of two methods of tooth-isolation on the survival rate of proximal ART restorations in the primary molars.

METHODS

The study was conducted in two rural divisions in Kenya, with 7 operators randomly paired to a group of 8 assistants. A total of 804 children each had one proximal cavity in a primary molar restored using the ART approach. During restorations 2 isolation methods, rubber dam or cotton wool rolls, and 3 brands of glass ionomer cements were used by the operators. The restorations were then followed for a period of 2 years.

STATISTICS

SPSS 14.0 was used to analyse and relate the data obtained to the method of isolation used.

RESULTS

After 2 years 30.8% of the ART restorations had survived. Higher survival rates of the restorations were obtained when using rubber dam irrespective of the GIC material or the operator.

CONCLUSION

Generally the survival rate of the proximal restorations in the present study was very low, but the use of rubber dam resulted in a higher survival rate of the restorations.

Two years survival rate of Class II ART restorations in primary molars using two ways to avoid saliva contamination

AIM

To compare the survival rates of Class II Atraumatic Restorative Treatment (ART) restorations placed in primary molars using cotton rolls or rubber dam as isolation methods.

METHODS

A total of 232 children, 6-7 years old, both genders, were selected having one primary molar with proximal dentine lesion. The children were randomly assigned into two groups: control group with Class II ART restoration made using cotton rolls and experimental group using rubber dam. The restorations were evaluated by eight calibrated evaluators (Kappa > 0.8) after 6, 12, 18 and 24 months.

RESULTS

A total of 48 (20.7%) children were considered dropout, after 24 months. The cumulative survival rate after 6, 12, 18 and 24 months was 61.4%, 39.0%, 29.1% and 18.0%, respectively for the control group, and 64.1%, 55.1%, 40.1% and 32.1%, respectively for the rubber dam group. The log rank test for censored data showed no statistical significant difference between the groups (P = 0.07). The univariate Cox Regression showed no statistical significant difference after adjusting for independent variables (P > 0.05).

CONCLUSION

Both groups had similar survival rates, and after 2 years, the use of rubber dam does not increase the success of Class II ART restorations significantly.

Influence of the cavity-size on the survival rate of proximal ART restorations in primary molars

AIM

To evaluate the influence of the size of proximal cavities on the survival rate of the atraumatic restorative treatment (ART) restorations.

DESIGN

A total of 804 children, aged 6-8 years, from a low socio-economic community, with an ART restorable proximal carious lesion in their primary molars, participated. Over a 3-week period, three 'experienced' and four 'inexperienced' operators randomly paired with four 'experienced' and four 'inexperienced' assistants, made the restorations at site using hand instruments. They randomly used Fuji IX, Ketac Molar Easymix and Ketac Molar Aplicap glass ionomer cements to restore the cavities, under randomly selected rubber dam and cotton roll isolation methods. The fillings were independently evaluated by nine trained and calibrated evaluators.

RESULTS

After 1 year, the survival rate of the fillings evaluated in the study was 44.8%. Irrespective of the other factors involved, restorations with the highest survival rate were of size between 2 and 3 mm (mesio-distal, bucco-lingual, and depth) or volumes 10.0-19.9 mm(3) (Chi-square, P = 0.002, KM mean survival of 345 days).

CONCLUSIONS

While the survival rates for class II ART restorations were still low, the choice of medium-sized proximal cavities gave better survival rates for this technique.