Is non-cavitated proximal lesion sealing an effective method for caries control in primary and permanent teeth? A systematic review and meta-analysis

Equivalence study of the resin-dentine interface of internal tunnel restorations when using an enamel infiltrant resin with ethanol-wet dentine bonding

This preregistered ex vivo investigation examined the dentinal hybrid layer formation of a resinous infiltrant (Icon), with reference to both thickness (HLT) and homogeneity when combined with modified tunnel preparation (occlusal cavity only) and internal/external caries infiltration. The adhesives Syntac and Scotchbond MP were used as controls (Groups 1 and 3) or in combination with Icon (Groups 2 and 4). A split-tooth design using healthy third molars from 20 donors resulted in 20 prepared dentine cavities per experimental group. The cavity surfaces (n = 80) were etched (37% H3PO4), rinsed, and air-dried. Rewetting with ethanol was followed by application of the respective primers. After labeling with fluorescent dyes, either Syntac Adhesive/Heliobond or Scotchbond MP Adhesive was used alone or supplemented with Icon. HLT, as evaluated by scanning electron microscopy, did not significantly differ (P > 0.05), and confocal laser scanning microscopy revealed homogeneously mixed/polymerized resin-dentine interdiffusion zones in all groups. Icon can be successfully integrated into an ethanol-wet dentine bonding strategy, and will result in compact and homogeneous hybrid layers of comparable thickness considered equivalent to the non-Icon controls, thus allowing for preservation of the tooth's marginal ridge and interdental space in the case of internal/external infiltration of proximal caries.

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.

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.

The effect of minimally invasive treatments on enamel microhardness and resistance to further demineralization

Objectives: The present study aimed to compare microhardness of inactive proximal lesions treated by resin infiltration, Er:YAG laser + resin infiltration and Bioactive glass, and investigate the resistance of treated lesions to further demineralization challenge. Methods: In this in-vitro study, 30 human molars with inactive proximal lesions were selected and randomly divided into three groups of 10. In group 1 (resin infiltration), the lesions were treated by a resin infiltrant (Icon). In group 2, the surface was conditioned by an Er:YAG laser prior to resin infiltration. The specimens in group 3 were remineralized by bioactive glass. The treated specimens were kept in artificial saliva for 1 week and then immersed in a demineralization solution for 8 weeks. Surface microhardness was measured at baseline (T0), after remineralization (T1) and after exposure to the demineralization solution (T2), and the difference in microhardness between time points (ΔVHN) was calculated. Results: Microhardness after demineralization (T2) was significantly lower than those of other intervals (P0.05). The statistical analysis revealed no significant difference either in ΔVHNT1-T0 or in ΔVHNT2-T1 among the study groups (P>0.05) Conclusion: Pretreatment by the Er:YAG laser prior to resin infiltration was more effective that other treatments in enhancing microhardness and protecting the tooth against acidic challenge. However, the difference between groups did not reach a statistical significance, implying the need for further studies to achieve more conclusive results.

Detecting Proximal Caries on Periapical Radiographs Using Convolutional Neural Networks with Different Training Strategies on Small Datasets

The present study aimed to evaluate the performance of convolutional neural networks (CNNs) that were trained with small datasets using different strategies in the detection of proximal caries at different levels of severity on periapical radiographs. Small datasets containing 800 periapical radiographs were randomly categorized into a training and validation dataset (n = 600) and a test dataset (n = 200). A pretrained Cifar-10Net CNN was used in the present study. Different training strategies were used to train the CNN model independently; these strategies were defined as image recognition (IR), edge extraction (EE), and image segmentation (IS). Different metrics, such as sensitivity and area under the receiver operating characteristic curve (AUC), for the trained CNN and human observers were analysed to evaluate the performance in detecting proximal caries. IR, EE, and IS recognition modes and human eyes achieved AUCs of 0.805, 0.860, 0.549, and 0.767, respectively, with the EE recognition mode having the highest values (p all < 0.05). The EE recognition mode was significantly more sensitive in detecting both enamel and dentin caries than human eyes (p all < 0.05). The CNN trained with the EE strategy, the best performer in the present study, showed potential utility in detecting proximal caries on periapical radiographs when using small datasets.

In vitro effect of resin infiltrant on resistance of sound enamel surfaces in permanent teeth to demineralization

OBJECTIVE

To investigate the effect of resin infiltrant on resistance of sound permanent enamel surfaces to demineralization.

METHOD

Eighty healthy premolars were sectioned to obtain enamel blocks from the buccal surface. Specimens with baseline surface microhardness values of 320-370 were selected. The experimental group were treated with resin infiltrant, while the control group was not. Specimens from each group were artificially demineralized and the surface microhardness values were measured again. Confocal laser scanning microscopy was used to measure the depth of demineralization and detect the penetration ability of the resin infiltrant. The specimens were subjected to a simulated toothbrushing abrasion test. Scanning electron microscopy was used to observe changes in the surface morphology of specimens after each of these procedures.

RESULTS

No significant differences between the experimental and control groups were observed in the baseline microhardness values or in the experimental group after resin infiltration compared with the baseline conditions. After artificial demineralization, the microhardness value in the control group was significantly lower than that in the experimental group (266.0 (±34.5) compared with 304.0 (±13.0), P = 0.017). Confocal laser scanning microscopy results showed that the demineralization depth in the control group was significantly deeper than that in the experimental group (97.9 (±22.8) µm vs. 50.4 (±14.3) µm, P < 0.001), and that resin infiltrant completely penetrated the acid-etched demineralized area of the tooth enamel with a mean penetration depth of 31.6 (±9.0) µm. Scanning electron microscopy showed that the surface morphology was more uniform and smoother after simulated toothbrushing. The enamel surface structure was more severely destroyed in the control group after artificial demineralization compared with that of the experimental group.

CONCLUSION

Resin infiltrant can completely penetrate an acid-etched demineralized enamel area and improve resistance of sound enamel surfaces to demineralization. Our findings provide an experimental basis for preventive application of resin infiltrant to sound enamel surfaces to protect tooth enamel against demineralization.

Nonrestorative treatment of initial caries lesion in primary teeth: a systematic review and network meta-analysis

OBJECTIVE

To identify the best available approach to avoid initial caries lesions progression in primary teeth.

MATERIALS AND METHODS

Search was performed in MEDLINE/Pubmed, Web of Science, Embase and CENTRAL databases until March 2021. Studies compared treatment options to avoid the initial caries lesion progression with at least 12 months of follow-up were included. Network meta-analyses were conducted considering the non-progression of caries lesions as an outcome.

RESULTS

Potentially eligible studies were screened (n = 2820) and eleven were included. Six studies evaluated the use of fluoride varnish, resin infiltration, sealing, and toothbrushing/flossing on proximal initial caries lesions. When considering occlusal surfaces, only two studies evaluating the ozone gas, fluoride varnish, resin infiltration, and sealants were included. For buccal/lingual surfaces, three studies evaluating toothbrushing, CPP-ACP paste, fluoride varnish, and resin infiltration were included. For all types of surfaces, the resin infiltration showed the best probability to avoid the progression of initial caries lesions.

CONCLUSION

The limited number of included studies, most with a high risk of bias and lack of hard outcomes, such as frank cavitation, makes it not feasible to recommend a specific management approach for initial caries lesion control in primary teeth with a high certainty of evidence. PROSPERO: #CRD42016037781.

Effect of intracanal cryotherapy on postoperative pain after endodontic treatment: systematic review with meta-analysis

Objectives

This study aimed to evaluate the effectiveness of final irrigation with cold saline solution after endodontic treatment compared with saline solution at room temperature against postoperative pain following endodontic treatment.

Materials and Methods

A broad search was performed in the PubMed, Web of Science, Scopus, Cochrane Library, Virtual Health Library (LILACS), and Grey Literature databases. Two independent reviewers performed data extraction, risk of bias using the Cochrane methodology, and certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Results

Eight studies were included in qualitative synthesis. Intracanal cryotherapy favored the reduction of postoperative pain in the systematic review. Four studies were included in meta-analyses. The meta-analysis showed that intracanal cryotherapy reduced postoperative pain in teeth with symptomatic apical periodontitis (SAP) at 24 hours. There was no association between intracanal cryotherapy and control (room temperature) groups in teeth with normal periapical tissue with respect to postoperative pain at 24 hours and 48 hours.

Conclusions

Intracanal cryotherapy was effective in reducing postoperative pain after endodontic treatment in teeth with SAP.

Minimally Invasive Therapies for the Management of Dental Caries—A Literature Review

In recent years, due to a better understanding of the caries pathology and advances in dental materials, the utilization of non-invasive and minimally invasive techniques that delay/obviate the need for traditional restorations has started gaining momentum. This literature review focuses on some of these approaches, including fluoride varnish, silver diamine fluoride, resin sealants, resin infiltration, chemomechanical caries removal and atraumatic restorative treatment, in the context of their chemistries, indications for use, clinical efficacy, factors determining efficacy and limitations. Additionally, we discuss strategies currently being explored to enhance the antimicrobial properties of these treatment modalities to expand the scope of their application.

The Evaluation of Different Treatments of Incipient Caries Lesions: An in Situ Study of Progression Using Fluorescence-based Methods

CLINICAL RELEVANCE

Effective methods to control incipient caries lesions are needed. In this investigation, several methods provide encouraging results.

SUMMARY

This study aimed to evaluate in situ the inhibition of incipient caries lesion progression using different treatment protocols and to evaluate the effectiveness of fluorescence-based methods (DIAGNOdent, DIAGNOdent pen, and VistaProof fluorescence camera [FC]) in monitoring this process. The research was conducted in four phases: (1) at baseline, (2) after a first cariogenic challenge, (3) after treatment modalities, and (4) after a second cariogenic challenge. Sixteen volunteers used intraoral acrylic palatal appliances, each containing six enamel blocks (n=96). The cariogenic challenge was performed using a 20% sucrose solution over a 14-day period. The appliances were removed eight times a day and, upon removal, two drops of the solution were placed onto each enamel block. The enamel blocks were randomly assigned to three treatment groups: fluoride varnish ([FV] Duraphat; n=32), resin infiltrant ([RI] Icon; n=32), and adhesive system ([AS] Scotchbond; n=32). At the end of each phase, the surface microhardness (SMH) was measured, and two trained examiners evaluated the specimens using fluorescence-based methods. In addition, integrated mineral loss (ΔΔZ; vol%.min x μm) and lesion depth (ΔLD; μm) were evaluated using transverse microradiography. A two-way analysis of variance and a Tukey post hoc test were calculated (α=5%). Significant differences in SMH were observed according to the treatment, phases, and interaction of factors (p<0.001). Treatment with FV resulted in significantly higher SMH values in phases 3 and 4 compared to RI and AS, with the last two treatments resulting in similar values (p>0.05). The ΔΔZ value was similar for FV and AS but significantly higher for RI (p=0.016). ΔLD was not significantly different among the groups (p=0.126). Significant differences in the measurement of fluorescence for each fluorescence-based method were observed between each phase of the study (p<0.05). It can be concluded that all treatments were effective in inhibiting the in situ progression of incipient lesions, although to different degrees, with minor mineral loss changes observed for the AS and FV. Besides, all fluorescence-based methods tested, except for that using the FC device, were effective in monitoring caries lesion progression.

Infiltration and sealing for managing non-cavitated proximal lesions: a systematic review and meta-analysis

Background

Infiltration and sealing are micro-invasive treatments for arresting proximal non-cavitated caries lesions; however, their efficacies under different conditions remain unknown. This systematic review and meta-analysis aimed to evaluate the caries-arresting effectiveness of infiltration and sealing and to further analyse their efficacies across different dentition types and caries risk levels.

Methods

Six electronic databases were searched for published literature, and references were manually searched. Split-mouth randomised controlled trials (RCTs) to compare the effectiveness between infiltration/sealing and non-invasive treatments in proximal lesions were included. The primary outcome was obtained from radiographical readings.

Results

In total, 1033 citations were identified, and 17 RCTs (22 articles) were included. Infiltration and sealing reduced the odds of lesion progression (infiltration vs. non-invasive: OR = 0.21, 95% CI 0.15–0.30; sealing vs. placebo: OR = 0.27, 95% CI 0.18–0.42). For both the primary and permanent dentitions, infiltration and sealing were more effective than non-invasive treatments (primary dentition: OR = 0.30, 95% CI 0.20–0.45; permanent dentition: OR = 0.20, 95% CI 0.14–0.28). The overall effects of infiltration and sealing were significantly different from the control effects based on different caries risk levels (OR = 0.20, 95% CI 0.14–0.28). Except for caries risk at moderate levels (moderate risk: OR = 0.32, 95% CI 0.01–8.27), there were significant differences between micro-invasive and non-invasive treatments (low risk: OR = 0.24, 95% CI 0.08–0.72; low to moderate risk: OR = 0.38, 95% CI 0.18–0.81; moderate to high risk: OR = 0.17, 95% CI 0.10–0.29; and high risk: OR = 0.14, 95% CI 0.07–0.28). Except for caries risk at moderate levels (moderate risk: OR = 0.32, 95% CI 0.01–8.27), infiltration was superior (low risk: OR = 0.24, 95% CI 0.08–0.72; low to moderate risk: OR = 0.38, 95% CI 0.18–0.81; moderate to high risk: OR = 0.20, 95% CI 0.10–0.39; and high risk: OR = 0.14, 95% CI 0.05–0.37).

Conclusion

Infiltration and sealing were more efficacious than non-invasive treatments for halting non-cavitated proximal lesions.

Influence of glide path kinematics during endodontic treatment on the occurrence and intensity of intraoperative and postoperative pain: a systematic review of randomized clinical trials

BACKGROUND

Preliminary canal enlargement (glide path preparation) may play a significant role in the development of pain. The aim of this systematic review of randomized clinical trials was to assess the influence of glide path kinematics during endodontic treatment on the occurrence and intensity of intraoperative and postoperative pain.

METHODS

A search was performed in June 2019 in six electronic databases (PubMed, Scopus, LILACS, SciELO, Embase and Web of Science) and two grey literature databases (OpenGrey and OpenThesis). The bibliographic references of the eligible articles were also hand-searched. The included clinical studies assessed the occurrence and intensity of intraoperative and/or postoperative pain after root canal preparation without glide path preparation (WGP) or with glide path preparation using manual (M-GP), continuous rotary (CR-GP), or reciprocating (R-GP) instruments. The primary outcome was the occurrence and intensity of intraoperative and postoperative pain, while analgesic consumption was the secondary outcome. The full texts of the eligible studies were analyzed by two reviewers who performed calibration exercises to verify the risk of bias and quality of the individual studies using the Joanna Briggs Institute Critical Appraisal tool.

RESULTS

From 1283 identified articles, only six studies were included in the qualitative analysis of the results, with a total sample of 884 patients/teeth. Three studies presented a high risk of bias, while three studies presented a moderate risk. Two studies reported that CR-GP causes lower pain levels than M-GP and WGP, and three studies showed no differences between CR-GP and R-GP. Regarding analgesic consumption, two studies found no differences among glide path kinematics, and one study reported lower consumption for CR-GP than for M-GP. Because of the limited number of studies and methodological differences, no statistical analyses were performed for the glide path kinematics comparisons.

CONCLUSIONS

Compelling evidence indicating a significantly different occurrence and intensity of pain among glide path kinematics is lacking. The systematic review protocol was registered in the PROSPERO database [CRD42020139989].

How to intervene in the caries process: proximal caries in adolescents and adults-a systematic review and meta-analysis

OBJECTIVES

For an ORCA/EFCD consensus, this systematic review assessed the question "How to intervene in the caries process in proximal caries in adolescents and adults".

MATERIAL AND METHODS

Separating between the management of initial and cavitated proximal caries lesions, Medline via PubMed was searched regarding non-operative/non-invasive, minimally/micro-invasive and restorative treatment. First priority was systematic reviews or randomized controlled trials (RCTs), otherwise cohort studies. After extraction of data, the potential risk of bias was estimated depending on the study type, and the emerging evidence for conclusions was graded.

RESULTS

Regarding non-invasive/non-operative care (NOC), no systematic reviews or RCTs were found. In cohort studies (n = 12) with a low level of evidence, NOC like biofilm management and fluoride was associated with a low proportion and slow speed of progression of initial proximal lesions. Minimally/micro-invasive (MI) treatments such as proximal sealants or resin infiltration (four systematic reviews/meta-analyses) were effective compared with a non-invasive/placebo control at a moderate level of evidence. Data on restorative treatment came with low evidence (5 systematic reviews, 13 RCTs); with the limitation of no direct comparative studies, sample size-weighted mean annual failure rates of class II restorations varied between 1.2 (bulk-fill composite) and 3.8% (ceramic). Based on one RCT, class II composite restorations may show a higher risk of failure compared with amalgam.

CONCLUSIONS

Proximal caries lesions can be managed successfully with non-operative, micro-invasive and restorative treatment according to lesion stage and caries activity.

CLINICAL RELEVANCE

Proximal caries treatment options like non-operative, micro-invasive and restorative care should be considered individually.

Efficacy of Proximal Resin Infiltration on Caries Inhibition: Results from a 3-Year Randomized Controlled Clinical Trial

This study reports 3-y outcomes of a split-mouth randomized clinical trial. Resin infiltration’s capacity to arrest caries lesion progression in noncavitated proximal lesions is affirmed. Forty-two consented young adults, blinded to tooth surface allocation, were treated with resin infiltration on 1 randomly selected surface and concurrently experienced a mock infiltration procedure on another. Both treatments were provided as an adjunct to the currently accepted standard-of-care regimen (periodic prophylaxis and serial fluoride varnish applications) appropriate for the management of high caries risk. Challenging periods of low oral hygiene compliance were expected. The primary outcome measure was 3-y radiographic lesion progression. Blinded investigators evaluated each study surface for lesion progression with a series of images obtained at intervals over the 3-y course of study. Proportions of progressing lesions were compared with McNemar’s test. Twenty-nine noncavitated lesion pairs in permanent posterior teeth demonstrating caries penetrating into inner enamel or outer dentin were included in the analyses. No adverse events were reported. Radiographic progression was recorded in 4 of 29 infiltrated lesions (14%) and 14 of 29 control lesions (48%, P < .003). Adjunct resin infiltration demonstrated a high 3-y efficacy of 71% (relative risk reduction). The prevented fraction was 86% for infiltration versus 52% for controls. Resin infiltration was 100% successful in arresting caries progression in inner enamel lesions (E2) and 64% in outer dentin lesions (D1). Supplementary microinvasive resin infiltration is significantly more efficacious in reducing proximal lesion progression than management by standard noninvasive therapy alone. Long-term results may shed light on whether this represents the arrest or delay of the caries disease process (ClinicalTrials.gov NCT01584024).

Randomized controlled clinical trial of resin infiltration in primary molars: 2 years follow-up

OBJECTIVE

The aim of this split-mouth, randomized, controlled clinical trial was to evaluate the efficacy of resin infiltration in controlling the progression of non-cavitated proximal lesions in primary molars after two-years follow-up.

METHODS

Fifty healthy children presenting at least two primary molars with proximal lesion detected radiographically (in the inner half of enamel or the outer third of dentin) were included in the study. The proximal lesions were randomly allocated into resin infltration + flossing (test group) or flossing (control group). All patients received oral hygiene instructions for daily brushing with fluoride toothpaste (1100 ppmF) and flossing. The proportion of caries progression was compared using the McNemar test. The main outcome after 2-years, caries progression in the radiography was assessed by pair-wise reading by an independent examiner who was blind regarding the treatment.

RESULTS

The sample comprised 28 (56%) girls and 22 (44%) boys with a defs of 7,3 (SD = 6,5), mainly of moderate (46%) to high (48%) caries risk. Results after one year were published previously. After 2-years, 29 (58%) patients were assessed. Caries progression was observed in 24.1% (7/29) of the test lesions, compared with 55.2% (16/29) of the control lesions (p = 0.012). The therapeutic effect was 31.1% and the relative risk reduction (RRR) was 56.3%. Eigth lesions from the control group and two lesions from the test group progressed to the inner third of dentin and were restored.

CONCLUSIONS

In conclusion, resin infiltration was more efficacious in controlling proximal caries lesions in primary molars than non-invasive approach alone.

CLINICAL SIGNIFICANCE

The results indicate that resin infiltration was an efficacious method in controlling proximal caries lesions in primary molars after 2 years, even in patients with high caries risk, reaffirming the results of 1-year follow-up.

Efficacy of Resin Infiltrate in Noncavitated Proximal Carious Lesions: A Systematic Review and Meta-Analysis

Objectives:

Resin infiltration is a minimally invasive technique for treating noncavitated proximal caries. It slows/stops the carious lesion progression rate by creating a diffusion barrier inside the porous enamel lesion body. The aim was to evaluate the efficacy of resin infiltration on noncavitated proximal carious lesions in primary and permanent teeth.

Materials and Methods:

The records were obtained using electronic and other sources. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to ensure transparent reporting. Eligible studies were randomized controlled trials evaluating the efficacy of resin infiltration for noncavitated proximal carious lesions by comparing it with control/placebo. Each included study was assessed concerning the “risk of bias” using the Cochrane Collaboration's “risk-of-bias” assessment tool. High risk-of-bias studies were excluded from the meta-analyses due to selective reporting matters. The statistics were performed by RevMan software (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark) utilizing the random effect model. The GRADE approach was implemented for assessing the quality of evidence.

Results:

From 106 studies identified, 17 were assessed for eligibility. After “risk-of-bias” assessment, two meta-analyses were conducted to eliminate the limitation of the significant heterogeneity between trials inspecting primary teeth (n = 2) and permanent teeth (n = 3). I² = 0% indicates the absence of statistical heterogeneity. The risk of carious lesions’ progression with resin infiltration was significantly lower in primary (risk ratio [RR]; 95% confidence interval [CI]: 0.48; 0.30–0.75, P = 0.001) and in permanent teeth (RR; 95% CI: 0.19; 0.11–0.33, P < 0.00001) compared to that of control/placebo. The GRADE approach revealed high quality of evidence.

Conclusion:

The available evidence conveys high confidence that proximal resin infiltration has superior efficacy in slowing/arresting the carious lesions’ progression rate in comparison to conventional management modalities.

Approximal sealings on lesions in neighbouring teeth requiring operative treatment: an in vitro study

OBJECTIVES

With this in vitro study we aimed to assess the possibility of precise application of sealant on accessible artificial white spot lesions (WSL) on approximal surfaces next to a tooth surface under operative treatment. A secondary aim was to evaluate whether the use of magnifying glasses improved the application precision.

MATERIAL AND METHODS

Fifty-six extracted premolars were selected, approximal WSL lesions were created with 15% HCl gel and standardized photographs were taken. The premolars were mounted in plaster-models in contact with a neighbouring molar with Class II/I-II restoration (Sample 1) or approximal, cavitated dentin lesion (Sample 2). The restorations or the lesion were removed, and Clinpro Sealant was placed over the WSL. Magnifying glasses were used when sealing half the study material. The sealed premolar was removed from the plaster-model and photographed. Adobe Photoshop was used to measure the size of WSL and sealed area. The degree of match between the areas was determined in Photoshop.

RESULTS

Interclass agreement for WSL, sealed, and matched areas were found as excellent (κ = 0.98-0.99). The sealant covered 48-100% of the WSL-area (median = 93%) in Sample 1 and 68-100% of the WSL-area (median = 95%) in Sample 2. No statistical differences were observed concerning uncovered proportions of the WSL-area between groups with and without using magnifying glasses (p values ≥ .19). However, overextended sealed areas were more pronounced when magnification was used (p = .01). The precision did not differ between the samples (p = .31).

CONCLUSIONS

It was possible to seal accessible approximal lesions with high precision. Use of magnifying glasses did not improve the precision.

Micro-invasive interventions for managing non-cavitated proximal caries of different depths: a systematic review and meta-analysis

OBJECTIVES

The aim of this study was to further evaluate the caries-arresting effectiveness of micro-invasive interventions for non-cavitated proximal caries and analyze their efficacy for caries lesions of different depths.

MATERIALS AND METHODS

Randomized clinical trials (RCTs) of micro-invasive interventions for non-cavitated proximal caries were included in this study. We searched the Cochrane Library, PubMed, Embase, and Web of Science on May 25, 2017, without restrictions. After duplicate study selection, data extraction, and risk of bias assessment, a meta-analysis of the odds ratios (OR) with 95% confidence intervals (95% CIs) and a publication bias analysis were conducted using Stata 12.0.

RESULTS

After 2195 citations were screened, 8 citations of seven studies with follow-up periods from 12 to 36 months were included. The subgroup analysis showed that resin infiltration and resin sealant, but not glass ionomer cement (GIC), could reduce the caries progression rate (resin infiltration: OR = 0.15, 95% CI 0.09 to 0.24; resin sealant: OR = 0.33, 95% CI 0.19 to 0.58; GIC: OR = 0.13, 95% CI 0.01 to 2.65). Further analysis of their efficacies for caries lesions of different depths indicated that resin infiltration could arrest progression of enamel caries and caries around the enamel-dentin junction (EDJ) (enamel: OR = 0.05, 95% CI 0.01 to 0.35; EDJ: OR = 0.07, 95% CI 0.01 to 0.70). However, when the outer third of the dentin was involved, resin infiltration yielded significantly different results compared with the control group (OR = 0.42, 95% CI 0.16 to 1.10). Resin sealant seemed to be ineffective regardless of the caries depth (enamel: OR = 0.62, 95% CI 0.13 to 3.00; EDJ: OR = 0.44, 95% CI 0.09 to 2.15; dentin: OR = 0.43, 95% CI 0.07 to 2.63).

CONCLUSIONS

Resin infiltration is effective in arresting the progression of non-cavitated proximal caries involved in EDJ, while the therapeutic effects of resin sealant for different caries depths still needs to be further confirmed.

CLINICAL RELEVANCE

Based on existing evidence, dentists should carefully select appropriate micro-invasive interventions according to the different depths of non-cavitated proximal caries.

Resin infiltration: An effective adjunct strategy for managing high caries risk-A within-person randomized controlled clinical trial

OBJECTIVES

Micro-invasive resin-infiltration has shown to inhibit lesion progression of proximal non-cavitated carious lesions, suggesting an alternative to early operative treatment. This split-mouth, randomized placebo-controlled clinical trial evaluated the effects of proximal lesion infiltration supplementary to standard-of-care management in high caries risk (HCR)-patients.

METHODS

Forty-two HCR-subjects with two similar interproximal posterior lesions received professional HCR-regimen including repeated F-varnish applications. Two affected E2/D1-surfaces were randomized and concurrently treated by resin-infiltration or mock-infiltration (control). Individually standardized digital radiographs provided visual determination of lesion-size distribution at baseline and 2-year follow-up. Data were analyzed by logistic regression and McNemar's test.

RESULTS

Thirty-two lesion pairs (76%) were evaluated after 2 years. Categorical lesion depths were not different between groups (P > .5). Comparative pairwise assessment (image sets BL-2 yr) showed significantly more progression in control (7) versus infiltration (1) lesions (P = .035). Cumulative prevented fraction after two years was 97% for infiltrated lesions versus 74% for control lesions.

CONCLUSIONS

Two-year follow-up showed resin infiltration to be a highly efficacious (RRR: 86-89%) therapy. Long-term follow-up is needed to strengthen the evidence for efficacy of resin-infiltration as an adjunct to standard-of-care HCR-regimen including F-varnish.

CLINICAL SIGNIFICANCE

Showing 24% more stabilized lesions, the resin-infiltrated group performed significantly better than their controls, confirming successful early lesion management. Adjunct resin-infiltration provided an effective micro-invasive approach to inhibit short-term lesion progression.

Sealing or infiltrating proximal carious lesions

OBJECTIVES

Micro-invasive treatment (sealing, infiltration) seems more efficacious to arrest early (non-cavitated) proximal carious lesions than non-invasive treatment (NI). Uncertainty remains as to the efficacy of sealing versus infiltration and the robustness of the evidence. We aimed to review and synthesize this evidence using pairwise and network meta-analysis (NMA) and to perform trial sequential analysis (TSA).

SOURCES

Searching three electronic databases (Medline, Embase, Cochrane Central) was complemented by hand searches and cross-referencing.

STUDY SELECTION

Randomized controlled trials comparing micro-invasive strategies against each other, NI or placebo for managing proximal carious lesions were included. The primary outcome was radiographically assessed lesion progression. Pairwise and Bayesian network meta-analyses as well as TSA were used for synthesis.

DATA

Thirteen split-mouth studies (486 participants, mean age 15 years) were included. Mean follow-up was 25 months (min/max 12/36 months). Firm evidence on the superior efficacy of sealing/infiltration over NI (OR; 95% CI: 0.25; 0.18-0.32) was reached. Firm evidence was also reached on the superior efficacy of sealing (OR; 95% CI: 0.29; 0.18-0.46, 7 studies) and infiltration (OR; 95% CI: 0.22; 0.15-0.33, 7 studies) over NI. One study compared infiltration versus sealing and found no significant difference (0.70; 0.34-1.47). Based on Bayesian NMA, infiltration was ranked first in 80% of the simulations (sealing 20%, NI 0%). The surface-under-the-cumulative-ranking (SUCRA) values were 0.90 for infiltration, 0.60 for sealing and 0.00 for NI. We did not detect significant inconsistency (p = 0.89, node-split).

CONCLUSIONS

Sealing or infiltration are likely to be more efficacious for arresting early (non-cavitated) proximal lesions than NI.

CLINICAL SIGNIFICANCE

Practitioners should strive to perform micro-invasive treatment instead of NI for early proximal lesions. The decision between sealing or infiltration should be guided by practical concerns beyond efficacy.

Efficacy of resin infiltration of proximal caries in primary molars: 1-year follow-up of a split-mouth randomized controlled clinical trial

OBJECTIVE

The main purpose of this split month, randomized, controlled clinical trial was evaluate the efficacy of caries infiltration in controlling the progression of non-cavitated proximal lesions in primary molars. Anxiety and time required for the caries infiltration was also evaluated.

MATERIALS AND METHODS

Fifty healthy children, 5 to 9 years, presenting two primary molars with proximal caries lesions (1/2 of the enamel or outer 1/3 of dentin), were included. Lesions were randomly allocated to the test group (fluoridated toothpaste + flossing + infiltration) or to the control group (fluoridated toothpaste + flossing). Caries risk was based on the Cariogram model. The main outcome after 1-year radiographic follow up was assessed by an independent blinded examiner A facial image scale (FIS) was applied to assess dental anxiety and time required to perform the infiltration was recorded.

RESULTS

Of the sample, 92.9% corresponded to high or medium caries risk. In 42 patients (1-year follow up), caries progression was observed in 11.9% (5/42) of the test lesions compared with 33.3% (14/42) of the control lesions (p < 0.05). Five control and three test lesions progressed to the middle 1/3 of dentin and were restored. No side effects were observed. Anxiety was both low before and after the treatment, and mean time required for the infiltration was 11.29 min (± 1.16 min).

CONCLUSIONS

Caries infiltration of proximal caries lesions in primary molars is significantly more efficacious than standard therapy alone (fluoride toothpaste + flossing).

CLINICAL RELEVANCE

Caries infiltration is an applicable and well-accepted method be used in children, representing a promising micro-invasive approach.

Preventive and Therapeutic Proximal Sealing: A 3.5-Year Randomized Controlled Clinical Trial Follow-Up

OBJECTIVE

The aim of this split-mouth, randomized controlled clinical trial was to evaluate the efficacy of proximal sealing for avoiding the development of new caries lesions or arresting incipient caries lesions on the mesial surface of first permanent molars (6m) abutting lesions on the distal surface of second primary molars (05d) in children at high caries risk.

METHODS

A total of 61 children 8-10 years old were selected based on the caries status of the proximal sites of 05d and 6m. Children with caries on 05d and caries-free 6m were placed in the preventive sealing group and children with caries on both 05d and 6m in the therapeutic group. The children in each group had one 6m surface pair and in each pair one 6m surface was randomly allocated to receive a preventive or therapeutic sealing. Using a split-mouth design, the other 6m surface in the pair served as control.

RESULTS

After 3.5 years, standardized follow-up radiographs were obtained for the 45 children who remained. In the preventive sealing group, 4 out of 30 (13.3%) sealed and 16 out of 30 (53.3%) unsealed sound 6m surfaces had developed new caries lesions (p = 0.004, McNemar test). In the therapeutic sealing group, the progression of the carious lesions on 6m was observed in 3 out of 15 sealed (20.0%) and 8 out of 15 (53.3%) unsealed caries control surfaces (p = 0.06).

CONCLUSIONS

Preventive sealing on sound 6m surfaces abutting 05d lesions in children at high caries risk efficaciously prevents the development of caries lesions. Therapeutically sealing active non-cavitated caries lesions reduces the progression.

Managing caries: the need to close the gap between the evidence base and current practice

Underpinned by a changing knowledge of the aetiology of caries and its sequelae, and assisted by established and advancing dental materials, there is growing evidence supporting less invasive management of dental caries based on the principles of minimal intervention dentistry. This narrative review assesses both the evidence and the adoption of less invasive caries management strategies and describes ways in which the gap between evidence and practice might be overcome. While there is increasing data supporting less invasive management of carious lesions, these are not standard in most dental practices worldwide. Usually, clinical studies focused on efficacy as outcome, and did not take into consideration the views and priorities of other stakeholders, such as primary care dentists, educators, patients and those financing services. Involving these stakeholders into study design and demonstrating the broader advantages of new management strategies might improve translation of research into practice. In theory, clinical dentists can rely on a growing evidence in cariology regarding less invasive management options. In practice, further factors seem to impede adoption of these strategies. Future research should address these factors by involving major stakeholders and investigating their prioritised outcomes to narrow or close the evidence gap.