When to intervene in the caries process? An expert Delphi consensus statement

Marginal integrity in minimally invasive molar resin composite restorations: Impact of polymerization shrinkage

OBJECTIVES

This study utilized non-linear finite element (FE) models to explore polymerization shrinkage and its impact on marginal integrity in molars following both selective caries removal (SCR) and conventional treatment. Specifically, we performed 2D in silico simulations to study residual stresses post-resin polymerization shrinkage and their influence on the marginal integrity of various restoration types.

METHODS

Initially, FE models were developed based on a cohesive zone framework to simulate crack propagation along the bonded interfaces between restoration and tooth structure in SCR-treated molars with class I and class II restorations. The modeled resin composite restorations first underwent polymerization shrinkage and were then subjected to various occlusal loading conditions. Stress magnitudes and distributions were identified to evaluate the margin integrity and predict the mechanism and location of interfacial failure.

RESULTS AND DISCUSSION

The FE models computed polymerization shrinkage stresses of less than 1 MPa, exerting a minor influence on the composite/tooth interface. Occlusal loading, however, significantly impacted the load-bearing capacity of the composite/tooth (c/t) interface, potentially jeopardizing the restoration integrity. Especially under bi-axial occlusal loading, interfacial debonding occurred in the vertical cavity walls of the class I restorations, increasing the risk of failure. Notably, SCR-treated teeth exhibited better margin integrity than restored teeth after complete caries removal (NCR). These findings provide valuable insights into the mechanical behavior of SCR-treated teeth under different loading conditions and highlight the importance of considering the load scenarios that may lead to failure at the c/t interface. By investigating the factors influencing crack initiation and delamination, this novel research contributes to the optimization of restorative treatments and aids in the design of more resilient dental restorations.

Restorations performance after selective caries removal to soft dentine: 18-month follow-up of a controlled clinical trial

OBJECTIVE

This randomized controlled clinical trial aimed to evaluate the clinical performance of composite resin restorations placed after selective caries removal to soft dentin (SCRSD) or stepwise excavation (SW) over an 18-month period.

METHODS

Inclusion criteria were patients with permanent molars and/or premolars presenting deep caries lesions (≥50% of the dentin thickness). Teeth were submitted to SCRSD (n=76) or SW (n=76). Evaluations were performed based on FDI (World Dental Federation) criterion. Survival analysis was performed to estimate the survival of restorations and its association with clinical variables and socio-demographic characteristics (adjusted Weibull regression model). The study was registered on Registro Brasileiro de Ensaios Clínicos (ReBEC 65ntbc).

RESULTS

The follow-up period ranged from 6 to 18 months (mean±SD 16.3±3.4 months). Patients' ages ranged from 9 to 55 years (mean±SD 29±10.5 years). A total of 135 teeth (SCRSD=72; SW=63) from 101 patients were evaluated. There were 4 failures in the SCRSD group (2 loss of restoration in need of replacement and 2 marginal fractures in need of repair) and 2 in the SW group (fracture in need of repair). The association between explanatory variables and restoration failure showed similar success rates for SW (99.4%) and SCRSD (97.9%) (p=0.16). Patients presenting gingivitis (≥20% of sites with gingival bleeding) had 8.50 times more risk for failure than those with <20% of bleeding sites (p=0.03).

CONCLUSION

This study showed that placing a composite resin restoration over soft dentin (after SCRSD) did not affect its clinical performance after 18 months.

CLINICAL SIGNIFICANCE

SCRSD is a feasible treatment option for the management of deep caries lesions in permanent teeth as it preserves tooth vitality and tooth structure without compromising restoration longevity.

Characterisation of experimental flowable composites containing fluoride-doped calcium phosphates as promising remineralising materials

OBJECTIVE

Remineralising composites with antibacterial properties may seal the cavity and prevent secondary caries. This study aimed at developing experimental flowable composites containing different concentrations of fluoride-doped calcium phosphate fillers and evaluating their remineralising and antibacterial properties.

METHODS

Experimental resin-based composites containing different concentrations (0-20 %) of fluoride-doped calcium phosphate fillers (VS10/VS20) were formulated. The release of calcium (Ca), phosphate (PO) and fluoride (F) ions was assessed for 30 days. Remineralisation properties were evaluated through ATR-FTIR and SEM/EDX after storage in simulated body fluid (SBF). The metabolic activity and viability of Streptococcus gordonii was also evaluated through ATP, CFU and live/dead confocal microscopy. The evaluation of specific monomer elution from the experimental composites was conducted using high-performance liquid chromatography (HPLC).

RESULTS

The composites containing VS10 showed the highest release of Ca, those containing VS20 released more F over time (p < 0.05), while there was no significant difference in terms of PO ions release between the groups (p > 0.05). A quick 7-day mineral precipitation was observed in the tested composites containing VS10 or VS20 at 10 %; these materials also showed the greatest antibacterial activity (p < 0.05). Moreover, the tested composites containing VS10 presented the lowest elution of monomers (p < 0.05).

CONCLUSIONS

Innovative composites were developed with low monomers elution, evident antibacterial activity against S. gordonii and important remineralisation properties due to specific ions release.

CLINICAL SIGNIFICANCE

Novel composites containing fluoride-doped calcium phosphates may be promising to modulate bacteria growth, promote remineralisation and reduce the risk of cytotoxicity related to monomers' elution.

Occlusal Caries Detection with Intraoral Scanners in Pediatric Dentistry: A Comparative Clinical Study

Background: The aim of this clinical study was to compare the occlusal caries detection (OCD) performance of the intraoral scanners (IOSs) Trios 4 (TIO, 3Shape) and Emerald S (EME, Planmeca) and the Diagnocam (DIA, KaVo) with the established visual (WHO) examination (VIS, reference method). Methods: Between 08/2022 and 02/2023, 60 children (mean age 9.6 ± 2.5 years) were examined as part of their regular dental checkups. OCD was performed at the tooth level, separately for primary and permanent unrestored teeth. Furthermore, two thresholds were analyzed: sound versus overall caries (pooled data of enamel and dentin caries, TH1) and pooled data of sound and enamel caries versus dentin caries (TH2). Results: The best agreement with the reference method (reliability) in both dentitions was obtained for DIA (ĸ = 0.829/ĸ = 0.846; primary/permanent teeth), followed by EME (ĸ = 0.827/ĸ = 0.837) and TIO (ĸ = 0.714/ĸ = 0.680). Similar results were shown for the diagnostic quality (sensitivity, specificity and area under the curve of the receiver operating characteristic curve), with higher values for TH1 than for TH2. Both IOSs and the DIA showed worse results than the reference method VIS. Conclusions: Currently, IOS should be used as an additional caries detection tool, especially for visualization, and cannot be recommended as a basic tool for diagnosis or invasive/noninvasive therapy decisions in OCD.

Brazilian dentist's knowledge of minimum intervention dentistry for caries management: application of a developed knowledge scale (MIDDeC-KS) and evaluation of its psychometric properties

AIM

To assess the knowledge of Brazilian dentists about Minimum Intervention (MI) using a Minimum Intervention Dentistry to Dental Caries-Knowledge Scale (MIDDeC-KS) and evaluate its psychometric properties.

MATERIALS AND METHODS

An online scale was developed to evaluate dentists' knowledge about MI. The higher the score, the greater the knowledge and vice versa. A preliminary study was carried out with 143 dentists to validate the MIDDeC-KS. For psychometric properties analysis, convergent and discriminant validity, test-retest reliability, and internal consistency of the instrument were assessed. After validation, MIDDeC-KS was applied to a representative sample of Brazilian dentists. T test for independent samples, Chi-square, and/or ANOVA one-way tests were applied.

RESULTS

The MIDDeC-KS convergent (Spearman's = 0.48) and discriminant (P = 0.001) validity and reliability (ICC = 0.85, α = 0.72 and ω = 0.74) were proved. The participants (n = 637) obtained an overall mean score of 7.4 ± 2.5. The sample was mainly composed of females (P < 0.01), who graduated over 10 years prior (P = 0.02), from public colleges (P < 0.01), and most were pediatric dentists (38.2%). The highest and lowest scores were reached by pediatric dentists (9.2 ± 1.6) and bucomaxillofacial professionals (3.1 ± 2.1), respectively. Brazilian dentists demonstrated more knowledge about diet, biofilm, and topical fluoride control (84.3%), while the Hall technique (31.9%), resin infiltrant (47.6%), and chemical mechanical caries removal (48.4%) were the least known MI techniques.

CONCLUSION

Brazilian dentists demonstrated more knowledge about preventive measures and less about more recent protocols, such as the Hall technique, resin infiltrant, and chemical mechanical caries tissue removal. Sufficient psychometric evidence of the MIDDeC-KS was found.

CLINICAL RELEVANCE

Identify dentist's knowledge about MI.

Improving the Communication of Dental Findings in Pediatric Dentistry by Using Intraoral Scans as a Visual Aid: A Randomized Clinical Trial

The aim of this first randomized clinical trial (RCT) was to determine whether intraoral scans (IOS) can be used as a visual aid to improve the communication of dental findings in pediatric dentistry. Therefore, 60 children (mean age 10.1 ± 3.3 years) and their accompanying parents/primary caregivers were examined between July 2022 and February 2023. Patients were randomly allocated to two groups: half of the participants were informed of the children's dental findings including treatment plans by verbal explanation alone (control group, n = 30), while the other half were informed using IOS (Trios 4, 3Shape) as a visual aid to support the verbal explanation (study group, n = 30). Both groups then completed a questionnaire regarding their children's diagnosis, treatment needs, planned therapy, and oral hygiene. Statistical analysis was performed using a t-test (p < 0.05). Overall, there was a significant difference between the two groups (p < 0.001) in terms of understanding the current oral situation of their children. While 85.5 ± 17.3% (mean ± standard deviation) of the answers were correct in the study group, only 57.2 ± 17.8% of the participants in the control group were capable of answering the questions correctly. In particular, the control group had difficulties answering the questions about treatment needs and therapy correctly. Within the limitations of this first pilot study, IOS can be clearly recommended as a visual aid to improve the communication of dental findings with PGs in pediatric dentistry.

Optical clearing agents based on metallic and dielectric nanoparticles for caries diagnostic by optical coherence tomography

OBJECTIVE

This study aimed to assess the effect of titanium dioxide (TiO2) and silver (Ag) nanoparticles dispersed in glycerol or water, serving as optical clearing agents nanocolloids (OCAs-NC), for improving optical coherence tomography (OCT) images and highlighting incipient lesions in ex vivo human teeth.

MATERIALS AND METHODS

Twelve human teeth with incipient lesions were divided into seven groups according to the OCA-NC; they were subjected to G1 (air), G2 (glycerol), G3 (TiO2 0.1%), G4 (TiO2 0.01%), G5 (TiO2 0.001%), G6 (AgNO3 10%), and G7 (AgNO3 100%). The OCA-NC was applied to the occlusal surface, and two-dimensional images of the specimens were analyzed using OCT (930 nm central wavelength; 100 nm bandwidth; 5 mW output power; axial resolution of 7/5.3 μm in water and air, respectively; lateral resolution of 8 μm; and light penetration depth of 1.6 mm inside the sample).

RESULTS

The findings demonstrated that the utilization of OCAs-NC containing metallic or dielectric nanoparticles (AgNO3 and TiO2) led to improved differentiation between sound and demineralized enamel on occlusal surfaces. Additionally, it enhanced the depth of image penetration when analyzing this hard tissue with OCT.

CLINICAL RELEVANCE

In the current context of minimally invasive dentistry, the use of OCAs-NC in conjunction with OCT can provide clinicians with early diagnosis, allowing for the determination of less/more invasive therapies and consequently halting the disease before cavitation of dental tissues occurs.

Integration of an evidence-based caries management approach in dental education: The perspectives of dental instructors

PURPOSE/OBJECTIVES

Evidence-based caries management (EBCM) has developed into an internationally recognized tool for integration of comprehensive non-surgical caries treatment in dental education. However, uptake of the EBCM approach remains uneven across Canadian dental schools. Our project sought to understand how dental instructors perceive the challenges and solutions to the integration of the EBCM approach in undergraduate clinical education.

METHODS

Using a qualitative descriptive design, we recruited a purposeful sample of clinical instructors supervising undergraduate dental students in caries-related dental care. Semi-structured, online interviews focused on the main characteristics of EBCM. Interviews were analyzed using the awareness, desire, knowledge, ability, and reinforcement (ADKAR) change management model to understand challenges with EBCM implementation in undergraduate education. The analysis process started with verbatim transcription; then, transcripts were coded deductively based on the interview guide and the ADKAR model domains, and inductively to generate emergent codes. Finally, thematic analysis was used to develop themes and subthemes.

RESULTS

We interviewed 11 dental instructors with a wide range of clinical experience. Our results show that participants had sufficient awareness regarding the need for the EBCM approach and portrayed a strong desire to participate in bringing curricular changes. Knowledge and ability of participants depended on their training, experience, and involvement in continuing education courses. A lack of standardized caries management practices, less chairside time, and poor remuneration for instructors were major barriers in EBCM clinical implementation. Potential solutions suggested included providing continuing education courses, credits for students for non-surgical caries management, and remunerating instructors for implementation.

CONCLUSIONS

In conclusion, most participants were aware of the need for a substantive change toward EBCM and demonstrated the desire to participate and improve its implementation. Our analysis showed that to facilitate full integration of the EBCM approach into the undergraduate dental clinics, organizational focus needs to be placed on the individual's knowledge and ability, with tailored efforts toward reinforcement.

Cost-effectiveness and Acceptance in Children and Parents of the Hall Technique: Systematic Review of Clinical Trials

AIMS

The purpose of this systematic review was to evaluate the cost-effectiveness and acceptance of children and their parents of the Hall technique (HT) for dental rehabilitation in pediatric dentistry.

BACKGROUND

The approach of the HT is that of minimally invasive treatment of the dental element and is used exclusively on primary molars. Various studies in the literature point to HT as a restorative option well accepted by children and parents and quite predictable, with low retreatment rates and good cost-effectiveness for the management of primary molars with carious lesions. However, no systematic review in the literature has approached randomized clinical trials on these topics to produce a high level of evidence and help establish clinical HT protocols.

REVIEW RESULTS

Eight articles were selected for the systematic review. The HT was more cost-effective than procedures using other restorative materials. Regarding acceptance, in terms of esthetics, high percentages of satisfaction were reported for parents and children, with a divergence between studies in the comparison of esthetic preference with atraumatic restorative treatment. However, when considering crown cementation pain, comfort, anxiety, preference, and satisfaction, the HT was generally better evaluated when compared to other restorative materials.

CONCLUSION

The HT is an excellent restorative option when considering cost-effectiveness and acceptance and is recommended for use in daily clinical practice.

CLINICAL SIGNIFICANCE

Results indicate that HT is superior to other restorative materials regarding its acceptance by children and parents in terms of pain, comfort, anxiety, and crown preference and satisfaction. There were also high percentages of satisfaction with esthetics. Hall technique may initially appear expensive for dentists, but its effectiveness over time and the lesser need for consultations and reinventions ensure better cost-benefit than other restorative materials. How to cite this article: Valentim FB, Moreira KMS, Carneiro VC, et al. Cost-effectiveness and Acceptance in Children and Parents of the Hall Technique: Systematic Review of Clinical Trials. J Contemp Dent Pract 2023;24(12):1016-1025.

Consensus for teaching dental caries in the Portuguese Language at Brazilian dental schools

The aim of this paper was to present a summary of the process of developing and preparing the final documents of the national consensus for teaching undergraduate Brazilian dental students the dental caries curriculum in the Portuguese language. The final document was developed in three steps: a) The ABENO and LAOHA cariology group invited experts from all five regions of Brazil to participate in the discussion. The theoretical support for crafting the first draft of the consensus was based on two publications: National Curriculum Guidelines of the Dentistry graduation in Brazil, Ministry of Education (2021) and the competences described in the European Core Curriculum for Cariology (ORCA-ADEE, 2011); b) The group of experts was divided into 5 working groups: G1-Domain, Main and Specific Competences, G2-Essential knowledge, G3-Life course perspective, G4-Social determinants and dental caries, G5- Glossary. The document was finalized by thoroughly reviewing the process using Delphi methodology; c) The 5-chapter document (one from each working group) was submitted to three open public consultations in 2022 (May-June, August, and October) using Google-forms. The suggestions (content/wording) were discussed within the group as: totally accepted, partially accepted, and rejected. A total of 192 suggestions were registered from 31 dental schools in all regions of Brazil. The number of suggestions received per Group were: 84, 28, 26, 24, 30 suggestions for G1, G2, G3, G4 and G5, respectively. The majority of suggestions were totally accepted by the group of experts (n = 172, 89.6%), 15 were partially accepted (7.8%), and 5 were rejected. Conclusion The final document could be considered to be the first national consensus for teaching the dental caries curriculum in Brazil.

White spot lesions in orthodontics: consensus statements for prevention and management

OBJECTIVE

To establish consensus recommendations for clinicians to manage white spot lesions (WSLs) during orthodontic treatment.

MATERIALS AND METHODS

Three task force members reviewed the literature to identify best practices for minimizing WSLs during orthodontic treatment. Each draft statement was read to the task force members by a facilitator, followed by voting, accepting, or editing if necessary. The statements were then sent electronically by an independent third party (Magellan Medical Technology Consultants Inc, Minneapolis, Minn) to a previously formed content validation panel consisting of 20 independent private practitioners and clinical academicians for validation.

RESULTS

Twenty-one statements were developed and sent for content validation. While 19 statements achieved a content validation index (CVI) of 0.78, two items did not. These items were edited by the task force members based on qualitative feedback from content validation participants. Each of these revised statements did achieve a CVI of 0.78 on second evaluation from the content validation panelists and therefore were included in this document.

CONCLUSION

To reduce the risk of WSLs, it is essential to implement individualized caries management measures based on a comprehensive assessment of the patient's oral and systemic health. Effective at-home and professional mechanical and chemical plaque control should be implemented for high-risk orthodontic patients. Fluoride to support prevention and materials such as orthodontic sealants should also be used to provide a physical barrier around the brackets in high-risk patients. By following these guidelines, orthodontic professionals can help promote oral health and minimize the need for restorative treatment.

Cost-effectiveness of school-based caries screening using transillumination

OBJECTIVES

School-based screening for caries lesions usually only employs visual-tactile detection means (standard of care). Near-infrared-light-transillumination (NILT) could be used to support school-based screening and to identify early proximal caries, facilitating referral and appropriate non- or micro-invasive management in dental practice.

METHOD

We assessed the cost-effectiveness of NILT for school-based caries screening. A German mixed-payers' perspective was adopted. A Markov model was used to simulate the consequences of true and false positive and negative detections and the subsequent decisions over the lifetime of initially 12 years old patients. Our health outcome was tooth retention in years. Costs were measured in Euro 2020. Monte-Carlo-microsimulations, univariate and probabilistic sensitivity analyses were conducted. The incremental cost-effectiveness ratio (ICER) and the cost-effectiveness-acceptability at different willingness-to-pay-thresholds were quantified.

RESULTS

NILT was minimally more effective (tooth retention for a mean (2.5-97.5%) 56 (53-59) years) and minimally less costly (515 (416-616) Euro) than standard of care (56 (50-59) years; 526 (427-628 Euro)). The ICER was -503 Euro/year, i.e. school-based caries screening using NILT saved money at higher effectiveness in the modelled population. The cost-effectiveness of NILT increased for payers with a willingness-to-pay for additional tooth retention time. The biggest driver of costs were (avoided) tooth replacements later in life.

CONCLUSIONS

NILT-based screening is likely to yield limited effectiveness gains and cost savings in the modelled populations. In countries where regular practice-based screening of children is less common than in Germany, the cost-effectiveness of NILT for school-based caries screening is likely higher.

CLINICAL SIGNIFICANCE

NILT-based caries screening in German schools is unlikely to be cost-effective. In countries with different utilization patterns or generally higher caries prevalence and risk, this may differ.

Risk Indicators for Noncavitated and Cavitated Carious Lesions in Preschool Children

OBJECTIVE

The aim of this study was to evaluate the risk indicators associated with noncavitated and cavitated lesions in preschool children.

METHODS

The cross-sectional study included 3- to 4-year-old healthy children (N = 741) recruited in a randomised controlled clinical trial. After obtaining written informed consent, parents completed a questionnaire about their child's sociodemographic background and oral health-related behaviours and parents' oral health-related knowledge and attitude. Caries and plaque were evaluated using International Caries Detection and Assessment System-II and Visible Plaque Index (VPI), respectively. Children were grouped according to their oral health status as being caries-free (CF), having only noncavitated lesions (NC), or having cavitated lesions (CL). The least absolute shrinkage and selection operator (LASSO) sparse multinomial regression was used to study the variables using 1 standard error above the minimum criterion set at P < .05.

RESULTS

The prevalence of children with NC and CL was 29.1% and 49.4%, respectively, with a prevalence of early childhood caries being 78.5%. The proportion of children who brushed twice or more than twice a day was highest in CF (71.7%), followed by NC (58.3%), and was least in CL (57.7%). A higher percentage of CL children (56.2%) had twice or more than twice the frequency of between-meal snacking than CF (41.7%) and NC (41.1%) (P < .001) children. The variables included with non-zero coefficients in the model were mean parental oral health knowledge, attitude score, and children's mean VPI score, and all were significant for CL; however, in NC, only VPI score was found to be significant.

CONCLUSIONS

Poor oral hygiene is the risk indicator associated with the presence of NC in preschool children, whilst poor oral hygiene and poor parental oral health knowledge and attitude are associated with the presence of cavitated lesions.

Radiopacity evaluation of different types of resin restorative materials using a digital radiography system

OBJECTIVES

The aim of the study was to evaluate and compare the radiopacity of 20 current dental resin composites with digital radiography.

METHODS

Ten specimens, 10-mm in diameter and 1-mm thickness, were prepared and radiographed using phosphor plates close to Al step wedges and tooth sections. The mean grey values (MGVs) were measured using an ImageJ software program and converted to equivalent Al thickness. Data were analyzed using one-way analysis of variance (ANOVA) and Tamhane post hoc test (p < 0.05). Correlation between mean radiopacity and filler content (wt% and vol%) of the tested materials was analyzed with linear regression analysis.

RESULTS

The radiopacity of all composites ranged from 1.32 mm Al (Estellite Flow Quick) to 3.41 mm Al (Charisma Classic). All the tested materials, except four restorative materials, had a radiopacity equal or higher than the enamel (p < 0.05). Linear regression revealed low correlation between the radiopacity and filler content of the composite.

CONCLUSION

Majority of the materials has appropriate radiopacity for dental restorations. There was great variation in radiopacity level, may clinically affect the diagnosis.

Framework for fiscal impact analysis of managing initial caries lesions with noninvasive therapies

BACKGROUND

Evidence-based noninvasive caries therapies for initial caries lesions are available in the United States. Fundamental differences between noninvasive therapies and the traditional surgical dental approach warrant a study of the financial scalability.

METHODS

The financial costs and benefits of fee-for-service clinics and payors were compared across 11 scenarios simulating the treatment of 1,000 initial caries lesions during a 3-year period. The scenarios included varying combinations of noninvasive therapies (that is, silver diamine fluoride, self-assembling peptide P11-4, and glass ionomer therapeutic sealants), no treatment, and various rates of 1- through 3-surface restorations to an estimated 2022 practice model. We used a decision tree microsimulation model for deterministic and probabilistic sensitivity analyses. We derived assumptions from an initial lesion and noninvasive therapy-focused cohort study with operations data from 16 sites accepting Medicaid in Alabama as a case study and clinical data from all 92 sites.

RESULTS

In comparison with the 2022 practice model assumed for this study, scenarios that produce mutually beneficial results for payors' savings and clinics' net profits and profit margins include self-assembling peptide P11-4, silver diamine fluoride on nonesthetic surfaces, and a mix of 3 noninvasive therapies. When considering the limited resources of chair and clinician time, the same scenarios, as well as silver diamine fluoride with restorations, emerged with substantially higher clinic net profit.

CONCLUSIONS

Hypothetical scenarios that include noninvasive therapies and minimize restorations achieve improved outcomes for all parties.

PRACTICAL IMPLICATIONS

Payors and clinicians should explore and implement noninvasive caries therapies to improve oral health for all. This study was registered at ClinicalTrials.gov. The registration number is NCT04933331.

Bioactive Restorative Materials Applied over Coronal Dentine-A Bibliometric and Critical Review

The objective of the research was to examine the scientific literature concerning restorative materials with bioactive properties for the purpose of covering dentin. Searches were performed in various databases including MEDLINE, Scopus, Web of Science, Cochrane Library, Lilacs/BBO, and Embase. Inclusion criteria involved studies that utilized the terms "dentin" and "bioactive", along with "ion-releasing", "smart materials", "biomimetic materials" and "smart replacement for dentin". The information extracted included the title, authors, publication year, journal and the country of affiliation of the corresponding author. The studies were categorized based on their study design, type of material, substrate, analytical method, and bioactivity. A total of 7161 records were recovered and 159 were included for data extraction. Most of the publications were in vitro studies (n = 149), testing different types of materials in sound dentine (n = 115). Most studies were published in Dental Materials (n = 29), and an increase in publications could be observed after the year 2000. Most of the articles were from the USA (n = 34), followed by Brazil (n = 28). Interfacial analysis was the most investigated (n = 105), followed by bond strength (n = 86). Bioactivity potential was demonstrated for most tested materials (n = 148). This review presents insights into the current trends of bioactive materials development, clearly showing a severe lack of clinical studies.

Revised FDI criteria for evaluating direct and indirect dental restorations-recommendations for its clinical use, interpretation, and reporting

OBJECTIVES

The FDI criteria for the evaluation of direct and indirect dental restorations were first published in 2007 and updated in 2010. Meanwhile, their scientific use increased steadily, but several questions from users justified some clarification and improvement of the living document.

MATERIALS AND METHODS

An expert panel (N = 10) initiated the revision and consensus process that included a kick-off workshop and multiple online meetings by using the Delphi method. During and after each round of discussion, all opinions were collected, and the aggregated summary was presented to the experts aiming to adjust the wording of the criteria as precisely as possible. Finally, the expert panel agreed on the revision.

RESULTS

Some categories were redefined, ambiguities were cleared, and the descriptions of all scores were harmonized to cross-link different clinical situations with possible management strategies: reviewing/monitoring (score 1-4), refurbishment/reseal (score 3), repair (score 4), and replacement (score 5). Functional properties (domain F: fracture of material and retention, marginal adaptation, proximal contact, form and contour, occlusion and wear) were now placed at the beginning followed by biological (domain B: caries at restoration margin, hard tissue defects, postoperative hypersensitivity) and aesthetic characteristics (domain A: surface luster and texture, marginal staining, color match).

CONCLUSION

The most frequently used eleven categories of the FDI criteria set were revised for better understanding and handling.

CLINICAL RELEVANCE

The improved description and structuring of the criteria may help to standardize the evaluation of direct and indirect restorations and may enhance their acceptance by researchers, teachers, and dental practitioners.

Effectiveness of non-operative approaches in active enamel carious lesions: a retrospective longitudinal study

The aim of the study was to investigate the effectiveness of non-invasive and micro-invasive treatments in active enamel carious lesions in high-caries-risk children. Clinical records of children treated in a dental school setting were retrospectively screened for active enamel carious lesions treated non-invasively (topical fluoride applications, oral hygiene instruction, or dietary guidance) or micro-invasively (sealant). The control of active carious lesions was set as the main outcome established by the combination of inactivation and non-progression of the lesions based on Nyvad and ICDAS criteria, respectively. Individual and clinical factors associated with the outcome were analyzed by Poisson regression. The sample consisted of 105 high-caries-risk children with a mean age of 8.3 (± 2.4) years. From a total of 365 active enamel carious lesions, most lesions (84.1%) were active non-cavitated carious lesions (ICDAS scores 1 and 2) and only 15.9% presented localized enamel breakdown (ICDAS score 3). Of these, 72.6% were inactivated and 92.1% did not progress (mean time of 6.5 ± 4.1 months). The prevalence of controlled carious lesions was higher among children older than 6 years (PR:1.43; 95%CI:1.00-2.03; p = 0.04) and in those with better biofilm control (PR:0.99; 95%CI: 0.98-0.99; p = 0.03). Non-operative approaches are effective for controlling active enamel carious lesions. The majority of active enamel carious lesions became inactive and did not progress after treatment. Caries control was associated with older children and better biofilm control.

Dental caries in a Norwegian adult population, the HUNT4 oral health study; prevalence, distribution and 45-year trends

OBJECTIVE

To investigate dental caries prevalence amongst adults in Central Norway and assess changes over the last 45 years.

MATERIALS AND METHODS

The cross-sectional HUNT4 Oral Health Study was conducted in 2017-2019. A random sample of 4913 participants aged ≥19 years answered questionnaires and underwent clinical and radiographic examinations. Data were compared to findings from previous studies in the same region conducted from 1973 to 2006.

RESULTS

Mean number of decayed, missing and filled teeth (D_3-5MFT) was 14.9 (95% CI 14.7, 15.1), 56% of adults had one or more carious teeth (D_3-5T) and 11.8% had ≥4 D_3-5T, with the mean number of 1.4 (95% CI 1.32, 1.42). For initial caries, mean D_1-2S was 3.8 (95% CI 3.7, 3.9), being the highest for 19-24-year-olds at 8.6 (95% CI 7.9, 9.3). Comparisons with earlier studies showed a decline in mean D_3-5MFT for 35-44-year-olds from 26.5 in 1973 to 10.8 in 2019. In 1973, 4.8% of 35-44-year-olds were edentulous, while in present study edentulousness was found only in individuals >65 years.

CONCLUSIONS

Despite a substantial reduction in caries experience over the last 45 years, untreated dentine caries was common, evenly distributed across all age groups. Initial caries particularly affected younger individuals, indicating a need to evaluate prevention strategies and access to dental services.

Management Thresholds for Molars With Occlusal Noncavitated Caries Lesions

AIM

There is sparse research on the effect of factors related to the dentist and patient in the caries management decision-making process. This in vitro study explored the influence of factors related to dentists and patients on the management decision of occlusal noncavitated caries lesions in children.

MATERIALS AND METHODS

Five investigators in the specialties of dental public health (DPH), paediatric, prosthetic, and operative dentistry and a general dentist (GDP) participated in this study. Initially, the investigators were asked to independently assess the occlusal surfaces of 175 noncavitated permanent molars and choose a management recommendation using 2 caries risk patients' scenarios. After 1 month, investigators were trained and calibrated to use the International Caries Detection and Assessment System (ICDAS) scoring system. Then, they examined the same teeth, recorded the highest/worst ICDAS score, and chose a management recommendation. Two weeks later, the investigators repeated the teeth examination using magnification loupes and again chose a management recommendation. The teeth were sectioned to study the relationship between the presence of caries and the management recommendations.

RESULTS

For the low- and the high-caries risk scenarios, ICDAS training increased the operative intervention by 20% to 27% and 14% to 22%, respectively, for both the GDP and the paediatric dentist (P < .0001). For the low-caries risk scenario, using the magnifying loupes increased the operative recommendations for the DPH, GDP, and the operative dentist by 5% to 23% (P < .05). Compared to the low-caries risk scenario, teeth for patients with high caries risk received more surgical interventions (9%-30%) at all examination conditions for the GDP and the paediatric and operative dentists (P < .0001).

CONCLUSIONS

For occlusal noncavitated caries lesions, enhancing dentists' caries detection skills had a significant impact on decisions of surgical intervention. This also influenced the appropriateness of the treatment recommended for the different caries risk groups.

Classification of a patient's caries activity based on lesion activity assessment among adults: findings from a prospective cohort study

OBJECTIVE

To investigate whether the classification of a patient's caries activity based on lesion activity assessment can predict the increment and progression of coronal and root caries lesions among adults.

METHODS

This population-based prospective cohort study followed 413 individuals (mean age 54.1) from southern Brazil for 4 years. Data collection included a questionnaire and clinical examination to record coronal/root caries and gingival recession. The main outcomes were caries increment measured as decayed, missing and filled tooth surfaces (DMFS) and caries progression (surface-level analysis). The main predictor variable was patients' caries activity at baseline ("caries-inactive" or "caries-active"). Negative binomial regression models (unadjusted and adjusted) were used.

RESULTS

Caries-active individuals were more likely to present DMFS increment than caries-inactive ones when migrations among DMFS components were considered (IRR [incidence risk ratio] = 1.26, 95%CI [confidence interval] = 1.01-1.58). On the other hand, no such association was found when these migrations were disregarded. The risk for coronal caries progression on filled surfaces was 90% higher among caries-active patients (IRR=1.9; 95%CI=1.4-2.6). In addition, patient's caries activity was able to predict higher risk for root caries progression in newly exposed root surfaces (IRR=1.9; 95%CI=1.0-3.6).

CONCLUSION

The classification of a patient's caries activity based on lesion activity was able to foresee lesion progression on the coronal and root surfaces more susceptible to caries among adults. Clinical relevance Classifying a patient's caries activity is a useful tool for the clinical management of dental caries in adults.

Resin Infiltration of Non-Cavitated Proximal Caries Lesions in Primary and Permanent Teeth: A Systematic Review and Scenario Analysis of Randomized Controlled Trials

The present study aimed to meta-analyze and evaluate the certainty of evidence for resin infiltration of proximal carious lesions in primary and permanent teeth. While resin infiltration has been shown efficacious for caries management, the certainty of evidence remains unclear. The protocol was registered with PROSPERO (CRD42018080895), and PRISMA guidelines have been followed. The databases PubMed, Embase, and Cochrane CENTRAL were systematically screened, complemented by hand searches and cross-referencing. Eleven relevant articles were identified and included, i.e., randomized controlled trials (RCTs) comparing the progression of resin infiltrated proximal caries lesions (combined with non-invasive measures) in primary or permanent teeth with non-invasive measures. Random-effects meta-analyses and trial sequential analyses (TSA) were performed for per-protocol (PP), intention-to-treat (ITT), and best/worst case (BC/WC) scenarios. Six included trials assessed lesions in permanent teeth and five trails assessed lesions in primary teeth. The trials had a high or unclear risk of bias. Risk of caries progression was significantly reduced for infiltrated lesions in the PP, ITT, and BC scenarios in both permanent teeth and primary teeth, but not in the WC scenario. According to the TSA, firm evidence was reached for all of the scenarios except the WC. In conclusion, there is firm evidence for resin infiltration arresting proximal caries lesions in permanent and primary teeth.

Clinical practice guideline adaptation for risk-based caries management in 18-55 year-old Iranian adults

PURPOSE

To adapt an evidence-based clinical practice guideline (CPG) for risk-based management of caries in 18-55 year-old Iranian adults.

METHODS

A multidisciplinary adaptation team reviewed evidence-based guidelines such as the NICE, SIGN, and ADA according to the defined clinical questions. In addition, databases such as the PubMed and Google Scholar were searched and CPGs were screened and appraised using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) tool. Clinical scenarios were developed and their level of evidence, clinical advantage and adaptability were assessed. Following a two-round ranking by experts, the final recommendations were selected using the RAND-UCLA appropriateness method.

RESULTS

Of 17 CPGs, 5 were selected as the source guidelines for adaptation. To assess the risk of caries in the adult population, reduced Cariogram (without saliva tests) and CAMBRA were suggested as diagnostic tools. In addition, 53 risk-based recommendations on the preventive care (including the use of fluoride toothpaste, fluoride, and chlorhexidine mouthwash, at home and in-office fluoride gel, fluoride varnish, mouth buffering, and sealant), operative intervention threshold, and follow-up interval were adapted for Iranian adults.

CONCLUSIONS

A guideline was adapted for risk-based management of dental caries in Iranian adults. This helps local dentists in decision making and promoting oral health of adults. Further research is needed to assess the external validity and feasibility of the adapted guideline in the Iranian population.

Minimally invasive selective caries removal: a clinical guide

An evolving understanding of the carious process, along with new research in adhesive restorative materials, has led to a more conservative, minimally invasive and biologically-based approach to managing dental carious lesions. The growing volume of literature has also demonstrated prognostic success in the selective caries excavation technique, subsequently preventing excessive tooth structure removal and injury to the dentine-pulp complex, which maintains pulp vitality and improves the long-term prognosis of the tooth. However, at present, there remains a limited volume of high-quality evidence to support selective caries removal, which subsequently could partly explain some resistance to its use in clinical practice. This clinical technique guide aims to demonstrate the management of carious lesions of moderate-to-deep depth in permanent teeth based on current minimally invasive dental literature.

Inhibition of tooth demineralization caused by Streptococcus mutans biofilm via antimicrobial treatment using hydrogen peroxide photolysis

OBJECTIVES

An antimicrobial technique utilizing hydroxyl radicals generated by the photolysis of 3% H₂O₂ has been developed recently. The present study aimed to evaluate the effect of H₂O₂ photolysis treatment on tooth demineralization caused by Streptococcus mutans biofilm.

MATERIALS AND METHODS

To induce tooth demineralization, S. mutans biofilm was allowed to form on the maxillary first molars collected from Wistar rats via 24-h culturing. The samples were immersed in 3% H₂O₂ and irradiated with 365-nm LED (H₂O₂ photolysis treatment). Viable bacterial counts in the biofilm were evaluated immediately after treatment and after an additional 30-h culturing by colony counting. The acidogenicity of the biofilm, re-established 30 h after treatment, was assessed by measuring the pH. The effect of H₂O₂ photolysis treatment on tooth demineralization was assessed by measuring the depth of the radiolucent layer in micro-CT images.

RESULTS

H₂O₂ photolysis significantly reduced viable bacterial counts in the biofilm to 3.7 log colony forming units (CFU)/sample, while the untreated group had 7.9 log CFU/sample. The pH of the biofilm re-established after treatment (6.6) was higher than that of the untreated group (5.3). In line with the pH measurement, the treatment group had a significantly lower depth of radiolucent layer in dentin than the untreated group.

CONCLUSIONS

H₂O₂ photolysis treatment was effective not only in killing the biofilm-forming S. mutans but also in lowering the acidogenicity of the biofilm. Thus, this technique could inhibit tooth demineralization.

CLINICAL RELEVANCE

H₂O₂ photolysis can be applicable as a new dental caries treatment.

Reframing perceptions in operative dentistry relating evidence-based dentistry and clinical decision making: a cross-sectional study among Jordanian dentists

BACKGROUND

The aim of the current study was to investigate current dental practice in operative dentistry in Jordan, and the relationship between evidence-based dentistry in caries research and decision making in clinical practice in operative dentistry.

MATERIALS AND METHODS

This cross-sectional study was conducted through a survey of dentists in Jordan. The survey aimed to explore the degree of knowledge and practice of evidence-based dentistry in caries research the dentists possess regarding clinical decision making in operative dentistry. The sample size was composed of (5811) dentists whom registered in Jordan Dental Association database. Descriptive statistics were generated and Chi-square test was used to examine associations between the different variables and the significance level was set at P < 0.05.

RESULTS

4000 responses were collected from the web-survey, response rate (68.83%). Nearly half of the surveyed dentists focus on the chief complaint of their patients (n = 2032, 50.8%) rather than doing full mouth assessment. Nearly two-thirds of dentists (n = 2608, 65.2%) treat lesions confined to enamel with operative treatment. Half of dentists use operative treatment when asked about the routine management of radiographically detected proximal caries confined to enamel. When treating incipient lesions, the majority (n = 3220, 80.5%) use preventive treatment. Three-quarters of dentists (n = 2992, 74.8%) treat deep dentinal caries by removing just the soft infected carious dentin, and treated old failed restorations with replacement.

CONCLUSION

In operative dentistry, the evidence-based research is not implemented clinically. To optimize relationship between evidence-based dentistry and clinical decision-making, dental curriculum has to be updated and modified constantly.

Hall technique for primary teeth: A systematic review and meta-analysis

Background

There has been a debate about the use of Hall Technique (HT), whether it can be considered as a standard technique for the management of carious primary molars.

Aim

To summarise the evidence on HT for managing dentine caries in primary teeth.

Design

MEDLINE, Embase, CENTRAL and Epistemonikos databases were searched for clinical studies conducted from 2007 to 2021 evaluating HT in primary teeth. Two reviewers independently screened, data extracted and quality assessed the studies.

Results

Eleven publications from eight unique studies were included. Four were of low risk of bias overall and five studies were included in a meta-analysis. Overall, HT was 49 % (RR 1.49 [95 % CI: 1.15–1.93], I² =89.5 %, p < 0.001) more likely to succeed. When compared to direct restorations, HT was 80 % more likely to succeed; while similar success was found when compared to conventional preformed metal crowns. HT was also over 6 times (RR 0.16 [95 %CI: 0.10–0.27], I² =0 %, p < 0.001) less likely to fail. Most of the studies included proximal or multi-surface lesions.

Conclusions

HT is successful option for the management of caries in primary teeth, particularly for proximal or multi-surface dentine lesions. It is well-tolerated by children and acceptable to parent, with mild adverse effects reported.

Best clinical practice guidance for treating deep carious lesions in primary teeth: an EAPD policy document

Purpose

The European Academy of Paediatric Dentistry (EAPD) has developed this best clinical practice guidance to help clinicians manage deep carious lesions in primary teeth.

Methods

Three expert groups conducted systematic reviews of the relevant literature. The topics were: (1) conventional techniques (2) Minimal Intervention Dentistry (MID) and (3) materials. Workshops were held during the corresponding EAPD interim seminar in Oslo in April 2021. Several clinical based recommendations and statements were agreed upon, and gaps in our knowledge were identified.

Results

There is strong evidence that indirect pulp capping and pulpotomy techniques, and 38% Silver Diamine Fluoride are shown to be effective for the management of caries in the primary dentition. Due to the strict criteria, it is not possible to give clear recommendations on which materials are most appropriate for restoring primary teeth with deep carious lesions. Atraumatic Restorative Technique (ART) is not suitable for multi-surface caries, and Pre-formed Metal Crowns (PMCs) using the Hall technique reduce patient discomfort. GIC and RMGIC seem to be more favourable given the lower annual failure rate compared to HVGIC and MRGIC. Glass carbomer cannot be recommended due to inferior marginal adaptation and fractures. Compomers, hybrid composite resins and bulk-fill composite resins demonstrated similar values for annual failure rates.

Conclusion

The management of deep carious lesions in primary teeth can be challenging and must consider the patient’s compliance, operator skills, materials and costs. There is a clear need to increase the use of MID techniques in managing carious primary teeth as a mainstream rather than a compromise option.

Assessment of the remineralisation induced by contemporary ion-releasing materials in mineral-depleted dentine

OBJECTIVES

Evaluate the ability of current ion-releasing materials to remineralise bacteria-driven artificial caries lesions.

MATERIALS AND METHODS

Standardised class I cavities were obtained in 60 extracted human molars. Specimens underwent a microbiological cariogenic protocol (28 days) to generate artificial caries lesions and then were randomly divided into four restorative groups: adhesive + composite (negative control); glass ionomer cement (GIC); calcium silicate cement (MTA); and resin-modified calcium silicate cement (RMTA). Microhardness analysis (ΔKHN) was performed on 40 specimens (10/group, t = 30 days, 45 days, 60 days in artificial saliva, AS). Micro-CT scans were acquired (3/group, t = 0 days, 30 days, and 90 days in AS). Confocal microscopy was employed for interfacial ultra-morphology analysis (2/group, t = 0 days and 60 days in AS). Additional specimens were prepared and processed for scanning electron microscopy (SEM) and FTIR (n = 3/group + control) to analyse the ability of the tested materials to induce apatite formation on totally demineralised dentine discs (60 days in AS). Statistical analyses were performed with a significance level of 5%.

RESULTS

Adhesive + composite specimens showed the lowest ΔKHN values and the presence of gaps at the interface when assessed through micro-CT even after storage in AS. Conversely, all the tested ion-releasing materials presented an increase in ΔKHN after storage (p < 0.05), while MTA best reduced the demineralised artificial carious lesions gap at the interface. MTA and RMTA also showed apatite deposition on totally demineralised dentine surfaces (SEM and FTIR).

CONCLUSIONS

All tested ion-releasing materials expressed mineral precipitation in demineralised dentine. Additionally, calcium silicate-based materials induced apatite precipitation and hardness recovery of artificial carious dentine lesions over time.

CLINICAL RELEVANCE

Current ion-releasing materials can induce remineralisation of carious dentine. MTA shows enhanced ability of nucleation/precipitation of hydroxyapatite compared to RMTA and GIC, which may be more appropriate to recover severe mineral-depleted dentine.

The stamp technique for direct restoration in a ICDAS 4 carious lesion: A 4-year follow-up

OBJECTIVE

This case report described the use of a stamping technique associated with a bulk fill composite to restore an ICDAS 4 carious lesion on a posterior tooth. The 4-year follow-up is also presented.

CLINICAL CONSIDERATIONS

A 32-year-old patient presented a carious lesion on tooth 36 with an underlying dark shadow at the dentin seen from the noncavitated enamel occlusal surface, which was compatible with an ICDAS 4 carious lesion. The lesion was radiographically detected and the caries disease was treated with dietary and hygiene habits orientations. Before accessing the lesion and selectively removing the carious tissue, an occlusal stamp was made by applying a flowable resin composite to copy the anatomy of the noncavitated enamel surface. The cavity was restored using a bulk fill resin composite (Opus Bulk Fill, FGM) with 4-mm-thick increments. Before curing the last increment, a Teflon band was adapted at the uncured bulk fill composite surface and the occlusal stamp made with the flowable composite was pressed against it to reproduce the natural characteristics and initial occlusal anatomy. The top surface was light-activated for 40 s. After 4 years, small wear could be seen in the restoration, but still within clinically acceptable levels.

CONCLUSION

The occlusal stamp technique allows reproduction of the natural anatomy of teeth affected by ICDAS 4 carious lesions with good clinical longevity over 4 years.

CLINICAL SIGNIFICANCE

This case report presents the use of the stamp technique to restore a tooth affected by an ICDAS 4 lesion, in which a carious process reached the dentin and the enamel anatomy was still preserved. The bulk fill resin composite associated with the occlusal stamp was chosen to quickly restore the cavity with clinical predictability. Bulk fill composites allow the insertion of up to 4-mm-thick increments and offer lower shrinkage stress, good clinical longevity and a less time-consuming procedure in cases of posterior teeth, especially if associated with the stamp technique.

Evaluation of bleaching agent effects on color and microhardness change of silver diamine fluoride-treated demineralized primary tooth enamel: An in vitro study

Background

The present study aimed to assess the impact of application of fluoridated- 10% carbamide peroxide (CP) with or without potassium iodide (KI) on silver diamine fluoride (SDF)-treated enamel surface in the primary teeth.

Methods

After stained-remineralized caries lesions (s-RCLs) creation, 96 teeth were randomly allocated to four experimental groups: Group 1:SDF-treated enamel followed by 8-h/day application of 10% CP for 2 weeks; Group 2: SDF-treated enamel followed by 15-min/day application of 10% CP for 3 weeks; Group 3: SDF + KI-treated enamel followed by 8-h/day application of 10% CP for 2 weeks; and Group 4: SDF + KI-treated enamel followed by 15-min/day application of 10% CP for 3 weeks. Enamel microhardness (EMH) test (n = 12) and spectrophotometric color assessment (n = 12) was performed at four stages: baseline (intact enamel), demineralized enamel, aged remineralized-stained enamel, and after final intervention. Sixteen samples were used for SEM evaluation. Data were analyzed with the paired t-test, one-way ANOVA, and Tukey’s post-hoc test (p < 0.05).

Results

EMH values in all groups showed significant decrease after demineralization (all, p < 0.00001). All samples showed complete recovery of EMH values (%REMH) after SDF application compared to demineralization (%REMH_SDF) (p = 0.971). Bleaching caused a slight decrease in %REMH for all groups. However, the differences were not statistically significant (p = 0.979). SEM findings revealed no changes in enamel porosity after bleaching. Bleaching application ameliorated the discoloration in all groups (all, p < 0.00001). All samples in Groups 2 and 4 had significantly lighter color after 21 days as compared to 14-day exposure to the bleaching material (both, p < 0.00001).

Conclusions

SDF application on demineralized primary tooth enamel completely recovered enamel microhardness. 10% carbamide peroxide effectively bleached SDF stain without causing significant decrease in EMH values. Color improvement was more evident with the use of KI immediately after SDF application. Both 15-min and 8-h application of fluoridated CP resulted in statistically similar color enhancement in primary teeth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02371-3.

How is the quality of the available evidence on molar-incisor hypomineralization treatment? An overview of systematic reviews

OBJECTIVE

This overview analyzed the quality of the systematic reviews (SRs) available on treatments for molar-incisor hypomineralization (MIH).

MATERIAL AND METHODS

Six electronic databases were searched (PubMed/MEDLINE, Scopus, Web of Science, LILACS, Brazilian Bibliography of Dentistry and Cochrane Library) until March 2022. Two reviewers independently performed the selection, the quality assessment (Assessment of Multiple Systematic Reviews 2 - AMSTAR-2), and the risk of bias assessment of the SR (Risk of Bias in Systematic Reviews - ROBIS).

RESULTS

Two hundred nine records were retrieved; after removing duplicates and applying the inclusion/exclusion criteria, 5 SRs remained. Three SRs were rated as showing critically low methodological quality and high risk of bias, and two were rated as moderate methodological quality and low risk of bias. The identified treatments that may be suitable for MIH were classified as (1) non-invasive - casein incorporated into toothpaste and sugar-free chewing gum, toothpaste containing arginine, 0.4% stannous fluoride gel; fluoride varnish; (2) micro-invasive - resin sealants for pits and fissures, microabrasion, dental whitening, resin infiltration; (3) invasive - ART restorations, indirect restorations (metal, composite, or ceramic); and (4) mixed intervention - stainless steel crowns.

CONCLUSION

Despite the considerable number of published papers included in this set of systematic reviews, the evidence supporting the effectiveness of treatments for treating MIH is limited due to the methodological quality and risk of bias of the systematic reviews, as well as the quality of the primary studies (PROSPERO: CRD42020144831).

CLINICAL RELEVANCE

Different treatments have been purposed for MIH treatment, but there is still not enough scientific evidence of good quality for the establishment of a definitive clinical protocol for the treatment of MIH.

Impedance Spectroscopy as a Tool for the Detection of Occlusal Noncavitated Carious Lesions

A total 302 teeth (148 molars and 154 premolars) corresponding to 152 patients aged ≥18 years were evaluated for caries using the ICDAS (International Caries Detection and Assessment System), fluorescence (DD, DIAGNOdent) and electrical impedance (IMS, CarieScan PRO) systems. Fissurotomy and intraoral radiographs were used as the gold standard. Accordingly, 27.5% (n=84) of the teeth were classified as sound, while 26.9% (n=81) had enamel involvement and 45.6% (n=138) presented carious lesions reaching the dentin. Sensitivity (Se), specificity (Sp), and the area under the curve (AUC) were, respectively, 90.7%, 87.8%, and 0.954 (IMS); 92.4%, 92.7%, and 0.954 (DD); and 79.0%, 72.3%, and 0.756 (ICDAS). With regard to Se and Sp, there were significant differences between ICDAS and DD (p<0.001) and between ICDAS and IMS (p=0.01), but not between IMS and DD (p=0.07). In relation to AUC, there were significant differences between ICDAS and DD (p<0.001), and between ICDAS and IMS (p<0.001), but not between IMS and DD (p>0.05). The correlations between fissurotomy and each method were 88.7% (IMS), 89.7% (DD), and 77.1% (ICDAS). Within the limitations of this study, clinically, the electrical system is not useful for differentiating between sound teeth and truly incipient caries lesions by itself. The fluorescence or electrical systems are recommended with the ICDAS to detect carious lesions in their early stages.

Attenuation of near-ultraviolet, visible and near-infrared light in sound and carious human enamel and dentin

Objectives

This in vitro study aimed to investigate the optical attenuation of light at 405, 660 and 780 nm sent through sound and carious human enamel and dentin, including respective individual caries zones, as well as microscopically sound-appearing tissue close to a carious lesion.

Materials and methods

Collimated light transmission through sections of 1000–125-µm thickness was measured and used to calculate the attenuation coefficient (AC). The data were statistically analysed with a MANOVA and Tukey’s HSD. Precise definition of measurement points enabled separate analysis within the microstructure of lesions: the outer and inner halves of enamel (D1, D2), the translucent zone (TZ) within dentin lesions and its adjacent layers, the enamel side of the translucent zone (ESTZ) and the pulpal side of the translucent zone (PSTZ).

Results

The TZ could be distinguished from its adjacent layers and from caries-free dentin at 125 µm. Sound-appearing dentin close to caries lesions significantly differed from caries-free dentin at 125 µm. While sound and carious enamel exhibited a significant difference (p < 0.05), this result was not found for D1 and D2 enamel lesions (p > 0.05). At 405 nm, no difference was found between sound and carious dentin (p > 0.05).

Conclusions

Light optical means enable the distinction between sound and carious tissue and to identify the microstructure of dentin caries partially as well as the presence of tertiary dentin formation. Information on sample thickness is indispensable when interpreting the AC.

Clinical relevance

Non-ionising light sources may be suitable to detect lesion progression and tertiary dentin.

Visible Occlusal Plaque Index Predicting Caries Lesion Activity

This study was undertaken to appraise the predictive validity of the Visible Occlusal Plaque Index (VOPI) in assessing occlusal caries lesion activity in adolescents. A total of 618 adolescents aged 10 to 15 y were examined at the beginning of the trial and 511 (82.7%) at the 2-y follow-up. Adolescents and parents answered questionnaires about demographics, oral health behavior, and family sociodemographic variables. The VOPI has a 4-point ordinal scale ranging from no plaque to heavy plaque. Molar teeth were assigned to group VOPI 0-1 (no/thin plaque; n = 2,539) and group VOPI 2-3 (thick/heavy plaque; n = 843). At baseline examination, occlusal surfaces at risk of transition (n = 3,382) were either sound (55%), inactive noncavitated lesions (21%), inactive cavitated lesions (1%), active noncavitated lesions (15%), or active cavitated lesions (7%). The relative risk (RR) for caries lesion transition was estimated. Sound occlusal surfaces with no or thin plaque were significantly more likely to remain sound (RR = 1.3; 95% confidence interval [CI]: 1.1-1.4) than those harboring thick or heavy plaque. Inactive noncavitated occlusal lesions presenting no or thin plaque were significantly less likely to progress to active noncavitated lesions (RR = 0.1; CI: 0.0-0.8) than their counterparts with thick or heavy plaque. Active noncavitated lesions harboring thick and heavy plaque had a significantly lowest chance of becoming sound (RR = 0.7; CI: 0.5-0.9) and a highest risk of remaining active (RR = 1.5; CI: 1.1-1.9). Stepwise logistic regression analyses were run according to surface status at baseline and showed that none of the nonclinical predictors were significant for the outcome. The presence of thick and heavy plaque on occlusal surfaces was a predictor for caries lesion development, progression and activity (P < 0.0001). In conclusion, besides being an additional clinical tool for oral hygiene assessment, the VOPI is a predictor for development, progression, and activity of occlusal caries lesion. This is of particular interest for assessment of occlusal lesions undergoing health-promoting transitions.

Should new operating procedures arising from COVID-19 make us re-think our management of deep caries?

COVID-19 has impacted heavily on the delivery of dental services within the UK, particularly in regards to aerosol generating procedures (AGPs). However, it has created an opportunity to reflect on how operative dental procedures, such as the management of dental caries, are undertaken. In light of recent evidence in favour of speed increasing contra-angle handpieces in combination with an electric micromotor to eliminate the generation of aerosols at certain speeds while still allowing the cutting of hard tooth tissue, albeit at a slower rate than the traditional air-turbine, this article explores the evidence for partial caries removal using the electric micromotor system. Aspects of maintaing the health of the pulpal tissue using this system and adopting a logical approach to placing adhesive direct resin composites to faciliate an optimum outcome for the patient are also explored.

Penetration ability and microhardness of infiltrant resin and two pit and fissure sealants in primary teeth with early enamel lesions

To determine the penetration depth and enamel microhardness (EMH) of an infiltrant resin and two fissure sealants in primary teeth with early enamel lesions. We randomly divided 174 sound teeth into six groups (n = 29): (1) phosphoric acid (PA) + Clinpro, (2) PA + Aegis, (3) Icon, (4) hydrochloric acid (HCl) + Clinpro, (5) HCl + Aegis, and (6) control. Percentage penetration (%PP) was analyzed by confocal laser scanning microscopy (n = 15). EMH was measured (n = 12), and the percentage of EMH recovery (%REMH) was calculated. Twelve samples were examined under a scanning electron microscope (SEM). All data were analyzed with the Kruskal–Wallis and one-way ANOVA tests (p < 0.05). Groups 3 and 4 showed the highest %PP (all, p < 0.05). Icon application led to significantly higher %REMH compared to the others (p < 0.05). Groups 2 and 5 showed the lowest reduction in %REMH after pH-cycling. Application of Icon and Clinpro with HCl pretreatment showed the greatest %PP. pH-cycling led to a decrease in %REMH for all of the materials, although this effect was lower in teeth treated with Aegis.

Precision dentistry—what it is, where it fails (yet), and how to get there

Objectives

Dentistry is stuck between the one-size-fits-all approach towards diagnostics and therapy employed for a century and the era of stratified medicine. The present review presents the concept of precision dentistry, i.e., the next step beyond stratification into risk groups, and lays out where we stand, but also what challenges we have ahead for precision dentistry to come true.

Material and methods

Narrative literature review.

Results

Current approaches for enabling more precise diagnostics and therapies focus on stratification of individuals using clinical or social risk factors or indicators. Most research in dentistry does not focus on predictions — the key for precision dentistry — but on associations. We critically discuss why both approaches (focus on a limited number of risk factors or indicators and on associations) are insufficient and elaborate on what we think may allow to overcome the status quo.

Conclusions

Leveraging more diverse and broad data stemming from routine or unusual sources via advanced data analytics and testing the resulting prediction models rigorously may allow further steps towards more precise oral and dental care.

Clinical significance

Precision dentistry refers to tailoring diagnostics and therapy to an individual; it builds on modelling, prediction making and rigorous testing. Most studies in the dental domain focus on showing associations, and do not attempt to make any predictions. Moreover, the datasets used are narrow and usually collected purposively following a clinical reasoning. Opening routine data silos and involving uncommon data sources to harvest broad data and leverage them using advanced analytics could facilitate precision dentistry.

New Caries Diagnostic Tools in Intraoral Scanners: A Comparative In Vitro Study to Established Methods in Permanent and Primary Teeth

The aim of this in vitro study was to systematically investigate new caries diagnostic tools, including three intraoral scanners, and compare them to established diagnostic methods. For a standardized analysis of occlusal and proximal caries lesions, human permanent and primary teeth (n = 64) were embedded in models and investigated in a phantom head using six different caries diagnostic methods: visual examination, bitewing radiography, Diagnocam (KaVo, Biberach, Germany), Trios 4 (3Shape, Copenhagen, Denmark), iTero Element 5D (Align Technology, San José, CA, USA), and Planmeca Emerald S (Planmeca, Helsinki, Finland). The diagnostic methods were investigated and compared to reference µ-CT for permanent and primary teeth separately. For occlusal caries diagnostics in permanent teeth, the best agreement to the reference (reliability) was obtained for Planmeca Emerald S (ĸ = 0.700), whereas in primary teeth, for visual examination (ĸ = 0.927), followed by Trios 4 (ĸ = 0.579). Regarding proximal caries diagnostics, bitewing radiography, as the gold standard, exhibited the highest agreement for permanent (ĸ = 0.643) and primary teeth (ĸ = 0.871). Concerning the analysis of the diagnostic quality (sensitivity and specificity) using receiver operating characteristic (ROC) curve analysis, comparable findings were obtained for area under curve (AUC) values as for reliability. No diagnostic method could be identified that is generally suitable for occlusal and proximal lesions in both dentitions. Overall, caries diagnostics with intraoral scanners seem to be interesting tools that should be further investigated in clinical studies.

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach

BACKGROUND

Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach.

METHODS

We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists.

RESULTS

Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care.

CONCLUSIONS

According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.

Cost-effectiveness of AI for Caries Detection: Randomized Trial

OBJECTIVES

We assessed the cost-effectiveness of AI-supported detection of proximal caries in a randomized controlled clustered cross-over superiority trial.

METHODS

Twenty-three dentists were sampled to assess 20 bitewings; 10 were randomly evaluated supported by an AI-based software (dentalXrai Pro 1.0.4, dentalXrai Ltd, Berlin, Germany) and the other 10 without AI support. The reference test had been established by four independent experts and an additional review. We evaluated the proportion of true and false positive and negative detections and the treatment decisions assigned to each detection (non-invasive, micro-invasive, invasive). Cost-effectiveness was assessed using a mixed public-private-payer perspective in German healthcare. Using the accuracy and treatment decision data from the trial, a Markov simulation model was populated and posterior permanent teeth in initially 31-years old individuals followed over their lifetime. The model allowed extrapolation from the initial detection and therapy to treatment success, re-treatments and, eventually, tooth loss and replacement, capturing long-term effectiveness (tooth retention) and costs (cumulative in Euro). Costs were estimated using the German public and private fee catalogues. Monte-Carlo microsimulations were used and incremental cost-effectiveness at different willingness-to-pay ceiling thresholds assessed.

RESULTS

In the trial, AI-supported detection was significantly more sensitive than detection without AI. However, in the AI group, lesions were more often treated invasively. As a result, AI and no AI showed identical effectiveness (tooth retention for a mean (2.5-97.5%) 49 (48-51)) and nearly identical costs (AI: 330 (250-409) Euro, no AI: 330 (248-410) Euro). 41% simulations found AI and 43% no AI to be more cost-effective. The resulting cost-effectiveness remained uncertain regardless of a payer's willingness-to-pay.

CONCLUSIONS

Higher accuracy of AI did not lead to higher cost-effectiveness, as more invasive treatment approaches generated costs and diminished possible effectiveness advantages.

CLINICAL SIGNIFICANCE

The cost-effectiveness of AI could be improved by supporting not only caries detection, but also subsequent management.

Digital surveillance: Monitoring the activity of Internet users searching for information related to early childhood caries

This study evaluated the behavior of Internet users from seven countries through the analysis of the monthly variation of the Relative Search Volume (RSV) for queries related to early childhood caries (ECC), retrieved by Google Trends application programming interface between January 2004 to December 2020. The association of RSV with years lived with disability (YLDs) for untreated dental caries in deciduous teeth and Internet penetration were tested by regression models. Forecasting models were developed to predict the interests until December 2021. Relevant topics linked to searches were assessed qualitatively. Increasing levels of interests were observed in most countries, regarding the comparison of periods 2004-2012 and 2013-2021, without influence of seasonality. These results were associated with YLDs only in France and with the Internet penetration in Mexico and France. Searches were mostly related to the definition, risk factors, and preventive care of ECC. The interests of Internet users in ECC-related information increased in the last years in all seven countries, although it was maintained low over time. It might indicate a lack of awareness about the negative consequences of the disease in the early stages of life. Specific policies should be developed toward the dissemination of oral health information and the prevention of the disease.

Effects of Silver Diamine Nitrate and Silver Diamine Fluoride on Dentin Remineralization and Cytotoxicity to Dental Pulp Cells: An In Vitro Study

Silver diamine nitrate (SDN) is expected to help control caries similar to silver diamine fluoride (SDF). The aim of this study was to determine the mineral precipitation in demineralized dentin and the cytotoxicity of SDN and SDF to dental pulp cells. Demineralized dentin specimens were prepared, and SDF, SDN, or water (control) was applied. The specimens were then remineralized in simulated body fluid for 2 weeks. The mineral precipitation in the specimens was examined using FTIR-ATR, SEM-EDX, and synchrotron radiation X-ray tomographic microscopy (SRXTM). Additionally, the cytotoxicity of SDF and SDN to human dental pulp stem cells was analyzed using an MTT assay. The increase in FTIR spectra attributable to apatite formation in demineralized dentin in the SDF group was significantly higher compared to the SDN and control groups (p < 0.05). Dentinal tubule occlusion by the precipitation of silver salts was detected in both SDF and SDN groups. The mineral density as shown in SRXTM images and cytotoxicity of both SDN and SDF groups were comparable (p > 0.05). In conclusion, SDF demonstrated superior in vitro apatite formation compared to SDN. However, the degree of mineral precipitation and cytotoxic effects of both were similar.

Remineralization effects of self-assembling peptide P11 -4 associated with three materials on early enamel carious lesions: An in vitro study

The aim of this study was to assess the remineralization of enamel caries lesions using the self-assembling peptide P11 -4 associated with different materials. Artificial early enamel lesions were prepared on 154 primary teeth. The samples were randomly divided into eight groups: (1) control, (2) P11 -4, (3) fluoridate toothpaste (FT), (4) P11 -4 + FT, (5) casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), (6) P11 -4 + CPP-ACP, (7) fluoridate bioactive glass toothpaste (BT), and (8) P11 -4 + BT. The surface enamel microhardness (EMH) and energy-dispersive X-ray spectroscopy (EDS) of the teeth were then measured at the baseline, after demineralization, and after 28 days of remineralization. The enamel surfaces were assessed by field emission scanning electron microscopy (FESEM) and atomic force microscopy (AFM). The data were analyzed with one-way analysis of variance (ANOVA) (p < .05). EMH after demineralization was significantly lower than the baseline value (p < .001). The interventions led to an enhanced percentage of EMH recovery (%REMH), which was higher in Groups 6 and 7. There was no significant difference between Groups 3 and 4. Groups 1 and 2 had the lowest %REMH. The mean calcium/phosphate weight percentage ratio of P11 -4 was significantly lower than the others (p < .001). The FESEM and AFM images revealed mineral deposition on the eroded enamel and reductions in surface roughness in Groups 5 and 7.

Restorative treatment decisions for carious lesions: Do Russian dentists and dental students apply minimal intervention dentistry?

BACKGROUND

The concept of minimal intervention dentistry (MID) includes both delayed restorative treatment and conservative caries removal, and is now recognised as an evidence-based approach for dental caries management. In order to determine if dental professionals in Russia are incorporating this concept into their clinical practice, we investigated the restorative treatment decisions of Russian dentists and dental students, and the factors associated with these decisions.

METHODS

We included 171 general dental practitioners and dental therapists (collectively referred to here as "dentists") from North-West Russia, and 76 dental undergraduate students from the Northern State Medical University in Arkhangelsk (response rate of 11.5% and 67.9%, respectively). Participants completed a questionnaire, which collected background information (sex, region of work, place of dental school graduation, practice type, years of working experience, working in an urban or rural area, and specialisation in restorative dentistry) and information on restorative treatment decisions for proximal and occlusal carious lesions of permanent teeth. Treatment options in accordance with MID were defined as intervention at dentin level and minimally invasive cavity preparation. Multinomial logistic regression was used for statistical analysis.

RESULTS

For the proximal carious lesion, 9.4% of participants said they would employ both MID treatment options; 60.7% said they would choose only one; and 29.9% said they would use neither option. For the occlusal carious lesion, the corresponding figures were 37.2%, 52.1%, and 10.7%. No differences in restorative treatment options were observed among general dental practitioners, dental therapists, and dental students. For the proximal carious lesion, dentists from regions outside Arkhangelsk had 4.15 (95% confidence interval [CI] 1.13-15.27) times higher odds of following one versus both MID treatment options. For the occlusal carious lesion, working experience above 15 years was associated with higher odds of using only one versus both MID treatment options (adjusted odds ratio = 3.04, 95% CI 1.33-6.91). Almost all respondents preferred tooth-coloured materials for restorations; more than 75% chose resin-based composite.

CONCLUSIONS

The majority of Russian dentists and dental students do not apply the MID concept when treating dental caries in permanent teeth. Clinical protocols on dental caries treatment and dental school curriculums should be updated to place an enhanced focus on evidence-based practice and preventive strategies. Further studies with larger samples of Russian dentists and dental students and alternative methods of recruitment are needed to validate our results.

Overtreatment in Restorative Dentistry: Decision Making by Last-Year Dental Students

To evaluate the tendency for overdiagnosis and overtreatment upon different clinical situations among last-year students from the degree in dentistry from Valencia University (Spain) during the 2018-2019 course. A questionnaire consisting of 10 case exemplifications examining the diagnosis, treatment, and clinician's attitude towards different common clinical situations regarding restorative dentistry was designed. Fifty-two students were surveyed, from whom 42 completed the questionnaire (80.77%). Data were analyzed descriptively. A total of 58.8% of the students correctly identified an early carious lesion in the occlusal surface of a molar, while 63.2% would perform unnecessary complementary tests for its diagnosis. The treatment for carious lesions in different evolutive phases with a vital pulp was correct between 51.2 and 92.7% of the cases. The treatment for irreversible pulp pathology and the restoration of the tooth with root canal treatment were adequately selected in 56.1% and 78.3% of the cases, respectively. For the repair of a faulty restoration, an overtreatment was proposed by 87.8% of the students. A tendency to perform unnecessary complementary tests for caries diagnosis was observed. Treatment caries proposals were in accordance with available evidence in the majority of the cases. Students tended to overtreat defective restorations and would perform unnecessary treatments in medically compromised patients.