How to intervene in the caries process in adults: proximal and secondary caries? An EFCD-ORCA-DGZ expert Delphi consensus statement

Interdisciplinary Delphi study by PROSEC North America: Recommendations on single indirect restorations made from ceramic and nonmetallic biomaterials for posterior teeth

OBJECTIVE

This article puts forward consensus recommendations from PROSEC North America regarding single indirect restorations made from ceramic and nonmetallic biomaterials in posterior teeth.

OVERVIEW

The consensus process involved a multidisciplinary panel and three consensus workshops. A systematic literature review was conducted across five databases to gather evidence. The recommendations, informed by findings from systematic reviews and formulated based on a two-phase e-Delphi survey, emphasize a comprehensive treatment strategy that includes noninvasive measures alongside restorative interventions for managing dental caries and tooth wear. The recommendations advocate for selecting between direct and indirect restorations on a case-by-case basis, favoring inlays and onlays over crowns to align with minimally invasive dentistry principles. The recommendations highlight the critical role of selecting restorative biomaterials based on clinical performance, esthetic properties, and adherence to manufacturer guidelines. They emphasize the importance of precision in restorative procedures, including tooth preparation, impression taking, contamination control, and luting. Regular follow-up and maintenance tailored to individual patient needs are crucial for the longevity of ceramic and nonmetallic restorations.

CONCLUSIONS

These PROSEC recommendations provide a framework for dental practitioners to deliver high-quality restorative care, advocating for personalized treatment planning and minimally invasive approaches to optimize oral health outcomes.

CLINICAL SIGNIFICANCE

The PROSEC North America recommendations highlight the importance of minimally invasive techniques in posterior tooth restorations using ceramic and non-metallic biomaterials. These principles prioritize tooth structure conservation and personalized treatment planning, essential for enhancing clinical outcomes and long-term oral health.

Organization for Caries Research-European Federation of Conservative Dentistry Consensus Report on Clinical Recommendations for Caries Diagnosis Paper II: Caries Lesion Activity and Progression Assessment

INTRODUCTION

This consensus paper provides recommendations for oral health professionals on why and how to assess caries activity and progression with special respect to the site of a lesion.

METHODS

An expert panel was nominated by the executive councils of the European Organization for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD). The steering committee built three working groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity and progression assessment, and (3) obtain individualized caries diagnoses. The experts of work group 2 phrased and agreed on provisional general and specific recommendations on caries lesion activity and progression, based on a review of the current literature. These recommendations were then discussed and refined in a consensus workshop followed by an anonymous Delphi survey to determine the agreement on each recommendation.

RESULTS

The expert panel agreed on general (n = 7) and specific recommendations (n = 6). The specific recommendations cover coronal caries on pits and fissures, smooth surfaces, proximal surfaces, as well as root caries and secondary caries/caries adjacent to restorations and sealants. 3/13 recommendations yielded perfect agreement.

CONCLUSION

The most suitable method for lesion activity assessment is the visual-tactile method. No single clinical characteristic is indicative of lesion activity; instead, lesion activity assessment is based on assessing and weighing several clinical signs. The recall intervals for visual and radiographic examination need to be adjusted to the presence of active caries lesions and recent caries progression rates. Modifications should be based on individual patient characteristics.

40-Year Outcome of Old-School, Non-Surgical Endodontic Treatment: Practice-Based Retrospective Evaluation

(1) Background: Non-surgical endodontic treatment has been shown to be clinically successful; however, clinical long-term data are scarce. This practice-based retrospective clinical investigation evaluated endodontic outcomes over 40 years and identified relevant clinical co-factors. (2) Methods: Two experienced dental practitioners in two different private dental practices treated 174 patients with 245 teeth from 1969 to 1993. After root canal obturation, either a new direct restoration (amalgam, resin composite, or glass-ionomer cement) or the re-cementation of a pre-existing prosthetic restoration or renewal of prosthetic restoration followed. Metal posts (operator A) or metal screws (operator B) were inserted when coronal substance loss was significant. The primary outcome (i.e., tooth survival) was achieved when the endodontically treated tooth was, in situ, painless and had full function at the end of the observation period. A secondary outcome, the impact of different prognostic factors on survival rate, was evaluated. (3) Results: The overall mean survival was 56.1% of all treated teeth after 40 years of clinical service, resulting in an annual failure rate of 1.1%. Most investigated clinical co-factors (jaw, tooth position, intracanal dressings, post/screw placement, and gender) showed no significant influence on survival. (4) Conclusions: Even with materials and techniques from the 1970s and 1980s, successful root canal treatment was achievable. Except for post-endodontic restorations, most of the evaluated factors had no significant influence on the clinical long-term survival of root canal-treated teeth.

ORCA-EFCD consensus report on clinical recommendation for caries diagnosis. Paper I: caries lesion detection and depth assessment

OBJECTIVES

The aim of the present consensus paper was to provide recommendations for clinical practice considering the use of visual examination, dental radiography and adjunct methods for primary caries detection.

MATERIALS AND METHODS

The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity assessment and (3) forming individualised caries diagnoses. The experts responsible for "caries detection and diagnostic methods" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous Delphi survey.

RESULTS

Recommendations (N = 8) were approved and agreed upon by the whole expert panel: visual examination (N = 3), dental radiography (N = 3) and additional diagnostic methods (N = 2). While the quality of evidence was found to be heterogeneous, all recommendations were agreed upon by the expert panel.

CONCLUSION

Visual examination is recommended as the first-choice method for the detection and assessment of caries lesions on accessible surfaces. Intraoral radiography, preferably bitewing, is recommended as an additional method. Adjunct, non-ionising radiation methods might also be useful in certain clinical situations.

CLINICAL RELEVANCE

The expert panel merged evidence from the scientific literature with practical considerations and provided recommendations for their use in daily dental practice.

Implementation of a communication curriculum in undergraduate dental education-students' opinions during a 5-year development phase

INTRODUCTION

Communication training has become an essential part of the dental curriculum. The aim of this study was to evaluate the communication curriculum developed and introduced 2016-2021 at the University of Bern, School of Dental Medicine (SDM), Switzerland.

MATERIALS AND METHODS

The curriculum was implemented cumulatively in three phases: (1) lectures and accompanying role plays, (2) forum theatre and trainer-based communication training and (3) self-assessment. Students were surveyed 2016-2021 at the end of each semester using anonymous online questionnaires with five-point Likert scales (0-4).

RESULTS

A total of 191 fourth- and fifth-year students were surveyed, and 165 (86.4%) questionnaires were analysed. The mean age of the participants was 24.2 ± 1.4 and 45.5% were female. While students' opinions about the need to communicate increased during weekly lectures in phase 1, their opinions about their ability to communicate simultaneously decreased. During phase 2, fourth-year students' opinions on the need to communicate with dental patients increased from 3.22 ± 0.61 to 3.73 ± 0.45 (p = .001), anticipated benefits for dentists increased from 2.78 ± 0.71 to 3.43 ± 0.57 (p = .001) and for patients from 3.00 ± 0.76 to 3.47 ± 0.63 (p = .022). Only in phase 3, opinions on the ability to communicate statistically significantly increased for both fourth- (2.34 ± 0.71 to 2.72 ± 0.60, p = .033) and fifth-year (2.20 ± 0.63 to 2.86 ± 0.59, p = .001) students. Preferred teaching and assessment methods were trainer-based communication trainings (73.1%), lectures (67.3%) and self-assessments in the student clinic (59.6%).

CONCLUSION

Communication curricula in dental education using methods such as lectures and trainer-based communication trainings may additionally need to include self-assessments to be effective from the students' perspective.

A Systematic Review of Clinical Practice Guidelines for Caries Prevention following the AGREE II Checklist

Untreated oral diseases are detrimental to overall well-being and quality of life and are in close relationship with social and economic consequences. The presence of strong evidence for caries primary and secondary prevention is a compulsory tool for the development of clinical practice guidelines (CPGs). This paper was aimed to assess systematically the importance of clinical practice guidelines in caries prevention management considering both the adult and pediatric populations and evaluate them using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Checklist. Records were extracted from EMBASE, SCOPUS, PubMed/Medline and seven other relevant guideline databases between 6 January and 14 February 2023. Two reviewers independently conducted the appraisal using the web-based platform My AGREE PLUS. Twenty-one guidelines/papers met the inclusion criteria and were reviewed. Eight CPGs included both primary and secondary prevention interventions, whereas thirteen presented a single preventive model. Overall, 12 guidelines were published in the USA. The mean AGREE II scores ranged from 35.4% to 84.3%. Of the total twenty-one included guidelines, twelve were classified as "Recommended", ranging from 56.3% to 84.3%, the others were described as "Recommended with modification", ranging from 35.4% to 68.9%. From the AGREE II analysis carried out, the CPGs included in this survey adopted a punctual methodological rigor but lacked applicative power. The present survey showed that the public, as the primary beneficiary, played a limited role in the development of the twenty-one CPGs. Hence, methodological improvement can better support high-quality CPG development in the future.

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.

Experimental Composite Resin with Myristyltrimethylammonium Bromide (MYTAB) and Alpha-Tricalcium Phosphate (α-TCP): Antibacterial and Remineralizing Effect

The aim of this study was to develop an experimental composite resin with the addition of myristyltrimethylammonium bromide (MYTAB) and α -tricalcium phosphate (α-TCP) as an antibacterial and remineralizing material. Experimental composite resins composed of 75 wt% Bisphenol A-Glycidyl Methacrylate (BisGMA) and 25 wt% Triethylene Glycol Dimethacrylate (TEGDMA) were produced. Some 1 mol% Trimethyl benzoyl-diphenylphosphine oxide (TPO) was used as a photoinitiator, and butylated hydroxytoluene (BTH) was added as a polymerization inhibitor. Silica (1.5 wt%) and barium glass (65 wt%) particles were added as inorganic fillers. For remineralizing and antibacterial effect, α-TCP (10 wt%) and MYTAB (5 wt%) were incorporated into the resin matrix (α-TCP/MYTAB group). A group without the addition of α-TCP/MYTAB was used as a control. Resins were evaluated for their degree of conversion (n = 3) by Fourier Transform Infrared Spectroscopy (FTIR). The flexural strength (n = 5) was assessed based on ISO 4049:2019 requirements. Microhardness was assessed to calculate softening in solvent (n = 3) after ethanol immersion. The mineral deposition (n = 3) was evaluated after immersion in SBF, while cytotoxicity was tested with HaCaT cells (n = 5). Antimicrobial activity (n = 3) was analyzed against S. mutans. The degree of conversion was not influenced by the antibacterial and remineralizing compounds, and all groups reached values > 60%. The α-TCP/MYTAB addition promoted increased softening of polymers after immersion in ethanol and reduced their flexural strength and the viability of cells in vitro. A reduction in S. mutans viability was observed for the α-TCP/MYTAB group in biofilm formation and planktonic bacteria, with an antibacterial effect > 3log₁₀ for the developed materials. Higher intensity of phosphate compounds on the sample's surface was detected in the α-TCP/MYTAB group. The addition of α-TCP and MYTAB promoted remineralizing and antibacterial effects on the developed resins and may be a strategy for bioactive composites.

Digital Application for Promoting Evidence-Based Children's Oral Health to Control Early Childhood Caries: Randomized Control Trial on Parental Acceptance and Efficacy

BACKGROUND

Early childhood caries (ECC) remains a major global health problem. Various measures to prevent it have been implemented in the past, including those using digital applications.

AIM

To evaluate the acceptance and efficacy of a digital application (FU-APP) based on evidence-based caries control recommendations for parents of children aged 6-72 months.

METHODS

Part 1, prospective questionnaire-based survey to test FU-APP (usage, acceptance, content information, usefulness, and satisfaction) filled out by parents (n = 22); Part 2, two-armed (test n = 20; control n = 23) care-based, randomized controlled trial, where the test arm received instructions verbally and via FU-APP, and the control arm received them only verbally. At baseline and follow-up (4 weeks), intraoral clinical indices (plaque index-API and caries-dmft) were recorded.

RESULTS

FU-APP was considered by parents to be a suitable tool for gaining knowledge about oral health practices for their children (all criteria >86%). No differences in the dmft levels were expected. However, API was significantly better at the follow-up in the test-arm (p = 0.01), with no differences in the control-arm (p = 0.72).

CONCLUSION

A digital application can serve as an innovative tool to promote evidence-based oral hygiene recommendations among parents of children to control ECC. Its long-term usability and functionality should be tested.

Dental Caries and Its Management

Objectives

In recent years, the management of dental caries has evolved significantly. Caries prevention, early detection, and a diagnosis based on risk indicators and risk factor assessments are the most current practical approaches. Furthermore, as proposed in minimally invasive dentistry, the new management approaches preserve healthy tissue and maintain pulp vitality. This article overviews the latest minimally invasive dental caries management and treatment options. The information will assist the reader in the early detection, diagnosis, and treatment of dental caries.

Materials and Methods

The PubMed (MEDLINE) search engine was used to gather the most relevant information on dental caries. The search was restricted to five years (May 30, 2018-May 29, 2022), and only English-language studies were accessed. A Boolean search of the PubMed data set was implemented to combine a range of keywords. The following filters were applied: abstract, free full text, full text, clinical trial, randomised control trial, systematic review, meta-analysis, and review. More studies were also obtained by manual searches from Google Scholar and textbooks on dental caries.

Results

By using this process, 683 articles and studies were obtained. The most relevant published studies were chosen and used in the current review. The selected articles are included in the references list. However, the search extended to cover the last five years as our understanding and management of dental caries have changed significantly.

Conclusions

Early detection and diagnosis of caries based on risk indicators and risk factor assessments are effective. Furthermore, minimally invasive restorative techniques are beneficial in managing dental caries and preserving healthy tissue and should be used whenever possible. This new information, knowledge, and materials should encourage professionals to implement this method. Having a strategy and system based on patient-centred care is critical, and our dental responsibilities must prioritise patient-centred care.

Cleansing efficacy of an auto-cleaning toothbrushing device with nylon bristles: a randomized-controlled pilot study

OBJECTIVES

To compare the cleansing efficacy of an auto-cleaning device with nylon bristles (Y-brush®) to that of manual toothbrushing.

MATERIALS AND METHODS

Twenty probands refrained from oral hygiene for 3 days. Rustogi Modified Navy Plaque Index was assessed before and after (randomized) toothbrushing either with the auto-cleaning device for 5 s per jaw or with a manual toothbrush for a freely chosen time up to 4 min. The clinical investigation was repeated in a cross-over design. In a third trial period, the brushing time for auto-cleaning was increased to 15 s per jaw. The study was supplemented by plaster cast analyses.

RESULTS

Full-mouth plaque reduction was higher with manual toothbrushing than with auto-cleaning for 5 s per jaw (p < 0.001). There was no statistically significant difference on smooth tooth surfaces but on marginal and interdental sites. Increasing the brushing time of auto-cleaning to 15 s per jaw resulted in a comparable full-mouth plaque reduction as with manual toothbrushing (p = 0.177). In 95% of individuals, the device was too short not completely covering second molars. In 30.67% of teeth, the gingival margin was not covered by bristles.

CONCLUSIONS

Auto-cleaning devices with nylon bristles have a future potential to reach plaque reduction levels comparable to manual toothbrushing, although manufacturers must focus on improving an accurate fit.

CLINICAL RELEVANCE

Under the premise of an ameliorated fit, the auto-cleaning device might be recommendable for people with low brushing efficacy. Interdental sites remain a failure point if adjunct interdental cleaning is not viable.

Randomized in situ evaluation of surface polishing protocols on the caries-protective effect of resin Infiltrant

The aim of this placebo-controlled randomized in situ study was to evaluate the effect of different surface polishing protocols on enamel roughness, bacterial adhesion and caries-protective effect of a resin infiltrant. Seventy-five bovine enamel samples having artificial caries lesions were treated with a resinous infiltrant and afterwards randomly dividided into five polishing protocols: aluminum oxide flexible disks (Al₂O₃-Disks), silicon carbide tips (SIC-Tips), silicon carbide brush (SIC-Brush), silicon carbide polyester strips (SIC-Strips) or no polishing [negative control (NC)]. Average surface roughness (Ra) was assessed by profilometry. Samples were mounted in palatal appliances under a mesh for biofilm accumulation. Fifteen volunteers wore the intraoral appliances (14-days) and cariogenic challenge was triggered by sucrose solutions. Biofilm formed was collected for microbiological analysis of caries-related bacteria (Streptococcus mutans, Lactobacillus acidophilus) and demineralization was assessed by cross-sectional microhardness. Mean Knoop hardness numbers (Kg/mm²) were plotted over lesion depth (µm) and area under the lesion curve was subtracted from sound enamel to determine demineralization (ΔS, Kg/mm²xµm). Data were analyzed by ANOVA and post-hoc comparisons (α = 0.05). NC resulted in significantly higher Ra means than Al₂O₃-Disks and SIC-Strips. Bacterial counts were not significantly different between the groups (p > 0.05). Regards ΔS means, however none of the groups were significantly different to NC (6983.3 kg/mm²xµm /CI 4246.1-9720.5, p > 0.05). Conclusions: Polishing protocols (Al₂O₃-Disks, SIC-Strips) significantly decreseased roughness of infiltrated-enamel, however none of the polishing protocols could signicantly decrease bacterial counts nor resulted in significant less demineralization.

Engineering peptide-polymer hybrids for targeted repair and protection of cervical lesions

By 2060, nearly 100 million people in the U.S. will be over age 65 years. One-third of these older adults will have root caries, and nearly 80% will have dental erosion. These conditions can cause pain and loss of tooth structure that interfere with eating, speaking, sleeping, and quality of life. Current treatments for root caries and dental erosion have produced unreliable results. For example, the glass-ionomer-cement or composite-resin restorations used to treat these lesions have annual failure rates of 44% and 17%, respectively. These limitations and the pressing need to treat these conditions in the aging population are driving a focus on microinvasive strategies, such as sealants and varnishes. Sealants can inhibit caries on coronal surfaces, but they are ineffective for root caries. For healthy, functionally independent elders, chlorhexidine varnish applied every 3 months inhibits root caries, but this bitter-tasting varnish stains the teeth. Fluoride gel inhibits root caries, but requires prescriptions and daily use, which may not be feasible for some older patients. Silver diamine fluoride can both arrest and inhibit root caries but stains the treated tooth surface black. The limitations of current approaches and high prevalence of root caries and dental erosion in the aging population create an urgent need for microinvasive therapies that can: (a) remineralize damaged dentin; (b) inhibit bacterial activity; and (c) provide durable protection for the root surface. Since cavitated and non-cavitated root lesions are difficult to distinguish, optimal approaches will treat both. This review will explore the multi-factorial elements that contribute to root surface lesions and discuss a multi-pronged strategy to both repair and protect root surfaces. The strategy integrates engineered peptides, novel polymer chemistry, multi-scale structure/property characterization and predictive modeling to develop a durable, microinvasive treatment for root surface lesions.

Caries risk assessment using different Cariogram models. A comparative study about concordance in different populations—Adults and children

This methodological survey aimed to verify whether there is concordance among several Cariogram different risk models at different thresholds, comparing both children and adult populations and how each risk/protective factor weight on the overall caries risk profile. Three groups’ data (two in children and one in adults) were obtained from previous studies, while a fourth, in young adults, was ad hoc enrolled. Different caries risk levels were assessed: a) three risk categories with two different thresholds as: “low risk”  =  61–100% or 81–100% chance to avoid caries, “moderate risk”  =  41–60% or 21–80% and “high risk”  =  0–40% or 0–20%, named model 1 and 2; b) four risk categories with two different thresholds as: “low risk”  =  61–100% or 76–100%, “moderate/low risk” = 41–60% or 51–75%; “moderate/high risk” = 21–40% or 26–50% and “high risk” = 0–20% or 0–25%, model 3 and 4; c) five risk categories as: “very low risk”  =  81–100%; “low risk”  =  61–80% “moderate risk” = 41–60%; “high risk” = 21–40% and “very high risk” = 0–20%, model 5. Concordance of the different Cariogram risk categories among the four groups was calculated using Cohen’s kappa. The weight of the association between all Cariogram models toward the Cariogram risk variables was evaluated by ordinal logistic regression models. Considering Cariogram model 1 and 2, Cohen’s Kappa values ranged from 0.40 (SE = 0.07) for the young adult group to 0.71 (SE = 0.05) for the adult one. Cohen’s Kappa values ranged from 0.14 (SE = 0.03 p<0.01) for the adult group to 0.62 (SE = 0.02) for the two groups of children in models 3 and 4. Statistically significant associations were found for all Cariogram risk variables excepting Fluoride program in models 4 and 5 and the overall risk on children’s samples. Caries experience showed a quite variable weight in the different models in both adult groups. In the regression analyses, adult groups’ convergence was not always achievable since variations in associations between caries risk and different risk variables were narrower compared to other samples. Significant differences in caries risk stratification using different thresholds stands out from data analysis; consequently, risk assessments need to be carefully considered due to the risk of misleadingly choosing preventive and research actions.

Comparison of two clinical approaches based on visual criteria for secondary caries assessments and treatment decisions in permanent posterior teeth

Background

This cross-sectional study aimed to compare two clinical approaches based on visual criteria for secondary caries assessments and treatment decisions in permanent posterior teeth.

Methods

The two clinical visual criteria tested for the assessments of restored teeth were: FDI criteria—based on the caries presence, marginal adaptation and staining criteria, adapted from the FDI (International Dental Federation) criteria and CARS criteria—"Caries Associated with Restorations or Sealants" (CARS) criteria described by the International Caries Classification and Management System. Adults were randomized according to the criteria. One calibrated examiner assessed the restorations and assigned the treatment according to the criteria. The primary outcome was replacement indication.

Results

A total of 185 patients were included, totalling 718 restorations. The strongest correlation founded between the methods was for the presence of caries lesions (Rho = 0.829). A moderate correlation (Rho = 0.420) was founded between the treatment decisions proposed by the CARS and by the FDI criteria. The multilevel regression analysis showed that the FDI criteria indicated five times more replacements when compared to the CARS (< 0.001). Also, using the FDI criteria restorations were 2.7 times more related to caries around restorations (p < 0.001) compared to the other criterion.

Conclusions

The visual criteria used on the restoration's assessment directly influences the treatment decision to intervene or not on the restoration. The use of a minimally invasive based approach for assessing secondary caries may prevent overtreatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02112-6.

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.

A universal adhesive containing copper nanoparticles improves the stability of hybrid layer in a cariogenic oral environment: An in situ study

PURPOSE

To evaluate how incorporating copper nanoparticles (CuNp) into a universal adhesive affects the antimicrobial activity (AMA), bond strength (μTBS), nanoleakage (NL), elastic modulus (EM) and nanohardness (NH) of resin-dentin interfaces, at 24 h (24 h) and after in situ cariogenic challenge (CC).

METHODS

CuNp (0% [control] and 0.1 wt%) was added to an adhesive. After enamel removal, the adhesives were applied to dentine surfaces. Each restored tooth was sectioned longitudinally to obtain two hemi-teeth; one of them was evaluated after 24 h, and the other was included in one of the intra-oral palatal devices placed in the mouths of 10 volunteers for 14 days in CC. After that, each hemi-tooth was removed, and any oral biofilm that formed was collected. The AMA was evaluated against Streptococcus mutans. For the 24 h and CC groups, each hemi-tooth was sectioned in the "x" direction to obtain one slice for each EM/NH evaluation. The remains of each hemi-tooth were sectioned in the "x" and "y" directions to obtain resin-dentin beams for μTBS and NL evaluation (24 h and CC). ANOVA and Tukey's test were applied (α = 0.05).

RESULTS

The presence of CuNp significantly improved AMA as well as all of the evaluated properties (24 h; p < 0.05). Although the adhesive properties (μTBS/NL) for all groups decreased after CC (p < 0.05), the adhesive containing CuNp showed higher μTBS and lower NL as compared to the copper-free adhesive (p < 0.05). The incorporation of CuNp maintained NH/EM values after CC (p < 0.05).

CONCLUSIONS

Adding 0.1% CuNp to an adhesive may provide antimicrobial activity and increase its bonding and mechanical properties, even under a cariogenic challenge.

SIGNIFICANCE

This is the first in situ study proving that incorporating CuNp into an adhesive is an achievable alternative to provide antimicrobial properties and improve the integrity of the hybrid layer under in situ cariogenic challenge.

Probiotics in the Management of Gingivitis and Periodontitis. A Review

In the management of intestinal health problems, the targeted use of probiotic microorganisms is a common therapeutic measure with a long-standing tradition. In clinical dentistry however, probiotics-based therapy is still a rather new and developing field, whose usefulness for the control of gingivitis and periodontitis has been questioned by recent meta-analyses and systematic reviews. The purpose of the subsequent descriptive review is to provide an introduction to the concept of probiotic microorganisms and their multifaceted health-promoting interactions with the human host and microbial competitors, followed by a detailed comparison of the results of available controlled clinical trials assessing the use of probiotics in the control of gingival and periodontal inflammations. It aims at contributing to a deeper understanding of the unique capabilities of probiotics to resolve chronic plaque-induced inflammation even in the absence of mechanical plaque control and will discuss how possible misconceptions about the rationale for using probiotics may have led to the present controversies about their usefulness as a therapeutic option.

Diagnosis and Management Approaches for Non-cavitated Carious Dental Lesions- A Narrative Review

Background:

Dental caries is one of the most prevalent diseases. Its detection and management should start with a comprehensive treatment plan, with the goals of the elimination of cariogenic bacteria, the reduction of plaque acidogenicity, the encouragement of tooth remineralization, and the repair of damaged teeth.

Objectives:

The aim of this paper was to review the literature regarding the latest updates on the diagnosis and management approaches of non-cavitated carious dental lesions.

Methods:

Studies regarding the diagnosis and management of non-cavitated carious dental lesions were included.

Results:

The subclinical non-cavitated carious lesion might progress to an early enamel lesion, develop into an established dentin lesion, or sometimes end up with a lesion reaching the pulp. The detection and management of caries should be patient-centered, risk-based, and evidence-supported, and should consider the dentists’ expertise and the patients’ needs and preferences. The visual-tactile and radiographic detection of non-cavitated carious lesions are greatly helped by the advances of non-invasive detection tools such as DIAGNOdent, fiber-optic transillumination, quantitative light-induced fluorescence, and DIAGNOcam.

Conclusion:

Accordingly, non-cavitated carious lesions can be arrested by several non-invasive techniques, which are preferred over the invasive options. The clinicians can use sealants plus fluoride varnish on occlusal surfaces, fluoride varnish or resin infiltration on proximal surfaces, and resin infiltration,fluoride gel, or varnish alone on facial or lingual surfaces to manage non-cavitated carious lesions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Interventions for treating cavitated or dentine carious lesions

BACKGROUND

Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

OBJECTIVES

To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

SEARCH METHODS

An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

MAIN RESULTS

We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

AUTHORS' CONCLUSIONS

Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Evolution of Network Structure and Mechanical Properties in Autonomous-Strengthening Dental Adhesive

The inherent degradation property of most dental resins in the mouth leads to the long-term release of degradation by-products at the adhesive/tooth interface. The by-products increase the virulence of cariogenic bacteria, provoking a degradative positive-feedback loop that leads to physicochemical and mechanical failure. Photoinduced free-radical polymerization and sol‒gel reactions have been coupled to produce a novel autonomous-strengthening adhesive with enhanced hydrolytic stability. This paper investigates the effect of network structure on time-dependent mechanical properties in adhesives with and without autonomous strengthening. Stress relaxation was conducted under 0.2% strain for 8 h followed by 40 h recovery in water. The stress‒time relationship is analyzed by nonlinear least-squares data-fitting. The fitted Prony series predicts the sample’s history under monotonic loading. Results showed that the control failed after the first loading‒unloading‒recovery cycle with permanent deformation. While for the experimental sample, the displacement was almost completely recovered and the Young’s modulus increased significantly after the first test cycle. The experimental polymer exhibited higher degree of conversion, lower leachate, and time-dependent stiffening characteristics. The autonomous-strengthening reaction persists in the aqueous environment leading to a network with enhanced resistance to deformation. The results illustrate a rational approach for tuning the viscoelasticity of durable dental adhesives.