Randomized controlled clinical trial of the 24-months survival of composite resin restorations after one-step incomplete and complete excavation on primary teeth

"Evaluation of Silver Diamine Fluoride Modified Atraumatic Restorative Treatment (SMART) on hypomineralized first permanent molar"- a randomized controlled clinical study

BACKGROUND

Restoring first permanent molars affected with molar incisor hypomineralization (MIH) is challenging. Focusing on improving the quality of life for children affected by MIH, at least until the complete eruption of first permanent molars to receive full coverage, to decrease the hypersensitivity and to be able to perform proper oral hygiene measures, the purpose of this study was to compare silver modified atraumatic restorative technique (SMART) versus the conventional restoration and fluoride varnish application on moderate to severe hypomineralized molars. The comparison considered the restoration survival, hypersensitivity, and digital surface area changes after one year follow up.

METHODS

Twenty-eight children were selected (20 girls and 8 boys) with at least 2 MIH molars with the same defect severity. The study comprised 2 groups; MOD group (moderate hypomineralized molar severity) and SEV group (Severe hypomineralized molar severity) (n = 28 tooth). Each group was further subdivided into 2 subgroups according to the technique of restoration: SMART subgroup and CONV subgroup (high viscosity glass ionomer restoration and fluoride varnish application) (each = 14 tooth). Evaluation was done in terms of the restoration survival (6 months and 12 months), hypersensitivity at 1 weak, 6 months and 12 months and occlusal surface area changes at 12 months). Professional Fluoride varnish application and home prophylaxis using MI paste were the protocol for each child patient.

RESULTS

There was no significant difference between the 4 subgroups, regarding tooth restoration integrity at 6-months vs. 12-months. However, a statistically significant difference in tooth restoration integrity between the 4 subgroups at 12-months (P = .049). Also, the hypersensitivity score, there was a statistically significant difference between the 4-time intervals (P < .001) and a statistically significant difference in surface area changes between the 4 subgroups.

CONCLUSIONS

Selective removal of carious tissue and SMART restoration, combined with dental home and professional preventive measures every 3 months maintained the integrity of restorations in severely and moderately affected permanent molars up to 1 year.

TRIAL REGISTRATION

The study protocol was retrospectively registered on Clinical Trials (NCT05931822-05/ 07/2023).

Aluminum zirconate nanoparticles in etch and rinse adhesive to caries affected dentine: An in-vitro scanning electron microscopy, elemental distribution, antibacterial, degree of conversion and micro-tensile bond strength assessment

To incorporate different concentrations of Al2O9Zr3 (1%, 5%, and 10%) nanoparticles (NP) into the ER adhesive and subsequently assess the impact of this addition on the degree of conversion, μTBS, and antimicrobial efficacy. The current research involved a wide-ranging examination that merged various investigative techniques, including the application of scanning electron microscopy (SEM) for surface characterization of NP coupled with energy-dispersive x-ray spectroscopy (EDX), Fourier-transform infrared (FTIR) spectroscopy, μTBS testing, and microbial analysis. Teeth were divided into four groups based on the application of modified and unmodified three-step ER adhesive primer. Group 1 (0% Al2O9Zr3 NPs) Control, Group 2 (1% Al2O9Zr3 NPs), Group 3 (5% Al2O9Zr3 NPs), and Group 4 (10% Al2O9Zr3 NPs). EDX analysis of Al2O9Zr3 NPs was performed showing elemental distribution in synthesized NPs. Zirconium (Zr), Aluminum (Al), and Oxides (O2). After primer application, an assessment of the survival rate of Streptococcus mutans was completed. The FTIR spectra were analyzed to observe the characteristic peaks indicating the conversion of double bonds, both before and after the curing process, for the adhesive Etch and rinse containing 1,5,10 wt% Al2O9Zr3 NPs. μTBS and failure mode assessment were performed using a Universal Testing Machine (UTM) and stereomicroscope respectively. The μTBS and S.mutans survival rates comparison among different groups was performed using one-way ANOVA and Tukey post hoc (p = .05). Group 4 (10 wt% Al2O9Zr3 NPs + ER adhesive) specimens exhibited the minimum survival of S.mutans (0.11 ± 0.02 CFU/mL). Nonetheless, Group 1 (0 wt% Al2O9Zr3 NPs + ER adhesive) displayed the maximum surviving S.mutans (0.52 ± 0.08 CFU/mL). Moreover, Group 2 (1 wt% Al2O9Zr3 NPs + ER adhesive) (21.22 ± 0.73 MPa) samples displayed highest μTBS. However, the bond strength was weakest in Group 1 (0 wt% Al2O9Zr3 NPs + ER adhesive) (14.13 ± 0.32 MPa) study samples. The etch-and-rinse adhesive exhibited enhanced antibacterial activity and micro-tensile bond strength (μTBS) when 1% Al2O9Zr3 NPs was incorporated, as opposed to the control group. Nevertheless, the incorporation of Al2O9Zr3 NPs led to a decrease in DC. RESEARCH HIGHLIGHTS: 10 wt% Al2O9Zr3 NPs + ER adhesive specimens exhibited the minimum survival of S.mutans. 1 wt% Al2O9Zr3 NPs + ER adhesive samples displayed the most strong composite/CAD bond. The highest DC was observed in Group 1: 0 wt% Al2O9Zr3 NPs + ER adhesive.

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.

Does the liner material influence pulpal vitality in deep carious cavities submitted to selective caries removal? A network meta-analysis review

OBJECTIVES

To evaluate whether the restorative material in direct contact with the dentin influences pulp vitality in primary and permanent teeth with deep carious lesions restored after selective caries removal (SCR).

MATERIAL AND METHODS

Systematic searches of databases MEDLINE via PubMed, Scopus and ISI Web of Science were performed for primary and permanent teeth. Inclusion criteria were applied for title and abstract reading of databases search results. After full texts review of included studies, those that did not meet exclusion criteria were excluded from meta-analysis.

RESULTS

For meta-analysis, 2 studies were included for permanent teeth and 6 for primary teeth. The failure events reported were meta-analyzed using two statistical methods: standard pairwise meta-analysis (SPMA) and network meta-analysis (NMA). The SPMA identified similar failure occurrence of restorations performed with calcium hydroxide (CH) and other liner materials (RR 0.84, 95% CI 0.41, 1.74; p = 0.64), no significant difference between the use of alternative liners or CH regardless deciduous or permanent teeth (RR 0.79, 95% CI 0.36, 1.71; p = 0.55) and similar risk of failing at different follow-ups for all liner materials tested (RR 0.77, 95% CI 0.35, 1.70; p = 0.52). Probabilistic analysis indicated GIC as liner material with the highest probability of clinical success (SUCRA = 72.76%), and CH ranked as the worst liner material (SUCRA = 21.81%).

CONCLUSION

Pulpal vitality was not affected by material used as liner after selective caries removal in deep carious cavities.

CLINICAL RELEVANCE

Current clinical evidence supports the weak recommendation to not use calcium hydroxide as liner after SCR.

One-year clinical evaluation of class II bulk-fill restorations in primary molars: a randomized clinical trial

This double-blind, randomized clinical trial aimed to compare the clinical performance and clinical time to restore occluso-proximal cavities in primary molars withbulk-fillresin and conventional resin. A total of 140 class II restorations in primary molars of 65 participants (mean age of 6.7 + 1.5) were placed in two random groups:bulk-filland conventional resin. The restorations were evaluated using FDI criteria at the baseline, 6-month, and one year by a single calibrated examiner, and the clinical restorative time was measured with a digital timer. The success and survival of the restorations were evaluated with Kaplan-Meier graphs. The log-rank test compared the curves. Differences in restorative clinical time were compared using the Mann-Whitney U test. The level of significance was 5%. After one year, 115 restorations were evaluated. The success probability was 88.7% for Filtek Z350 XT and 85.9% for FiltekTM Bulk-fill, and for the survival probability, Filtek Z350 XT presented 90%, and FiltekTM Bulk-fill presented 93.7%. No significant difference was found between the success and survival curves (p=0.62), (p=0.51). The main reason for failure was marginal adaptation.Bulk-fillresin required 30% less time than the conventional resin (p<0.001).Bulk-fillresin presented similar clinical performance to the conventional resin and required less restorative clinical time. It is an option to restore class II lesions of primary molars.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical effectiveness of restorative materials for the restoration of carious lesions in pulp treated primary teeth: a systematic review

Purpose

To systematically review the clinical performance of restorative materials after pulp therapy of carious primary teeth. It is part 2 of a systematic review on the clinical effectiveness of restorative materials for the management of carious primary teeth supporting the European Academy of Paediatric Dentistry (EAPD) guideline development.

Methods

Four electronic databases were systematically searched up to December 28th, 2020. Randomised controlled clinical trials (RCTs) on restorative materials for the restoration of carious primary teeth after pulp therapy were included. Failure rate, annual failure rate (AFR) and reasons for failure were recorded. Studies were sorted by restorative materials. The Cochrane Risk of bias tool for randomised trials (RoB 2.0) was used for quality assessment.

Results

After identification of 1685 articles and screening of 41 papers from EAPD review group 1, 5 RCTs were included. Restored primary molars with pulpotomy presented the following AFRs: composite resin (CR) 0%, preformed metal crowns (PMCs) 2.4–2.5%, resin-modified glass-ionomer cement combined with CR 3.8%, compomer 8.9%, and amalgam 14.3%. Maxillary primary incisors receiving pulpectomy exhibited AFRs of 0–2.3% for composite strip crowns (CSCs) depending on the post chosen. Reasons for failure were secondary caries, poor marginal adaptation, loss of retention and fracture of restoration. All studies were classified as high risk of bias. Meta-analyses were not feasible given the clinical/methodological heterogeneity amongst studies.

Conclusion

Considering any limitations of this review, CR and PMCs can be recommended for primary molars after pulpotomy, and CSCs for primary incisors receiving pulpectomy. However, a need for further well-designed RCTs was observed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40368-022-00744-4.

Clinical effectiveness of restorative materials for the restoration of carious primary teeth without pulp therapy: a systematic review

Purpose

To systematically search the available evidence and evaluate the clinical effectiveness of restorative materials for restoration of carious primary teeth. The findings aimed to support the European Academy of Paediatric Dentistry (EAPD) guidelines development.

Methods

Literature search was performed by searching 4 electronic databases for eligible randomised controlled clinical trials (RCTs) comparing restorative materials for the restoration of carious primary teeth up to December 28th, 2020. Quality assessment was performed with the revised Cochrane risk-of-bias tool for randomized trials (RoB 2).

Results

Of 1685 identified articles 29 RCTs were finally deemed as eligible for inclusion. Annual failure rates were: Amalgam 1–28%; atraumatic restorative treatment 1.2–37.1%; glass-ionomer cement (GIC) 7.6–16.6%, metal-reinforced GIC 29.9%, resin-modified GIC 1.9–16.9%, high-viscosity GIC 2.9–25.6%; glass carbomer ≤ 46.2%; compomer 0–14.7%; composite resin (CR) 0–19.5%, bulk-fill CR 0–16.9%; zirconia crowns 3.3%, composite strip crowns 15%, and preformed metal crowns (Hall-Technique) 3.1%. Secondary caries, poor marginal adaptation, loss of retention, and fracture of restoration were reported as reasons for failure. Four studies were evaluated at unclear and 25 at high risk of bias. Clinical and methodological heterogeneity, and the diversity of tested materials across included studies did not allow for meta-analyses.

Conclusions

Within the limitations of this systematic review, namely, the heterogeneity and the overall high risk of bias among included studies, clear recommendations based on solid evidence for the best restorative approach in primary teeth cannot be drawn. There is a need for future thoroughly implemented RCTs evaluating restorations in primary teeth to close this knowledge gap.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40368-022-00725-7.

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.

Management of dental caries lesions in Latin American and Caribbean countries

Caries management at the lesion level is dependent on the lesion activity, the presence of a cavitation (either cleanable or non-cleanable), and lesion depth as evaluated via radiographic examination. A variety of non-invasive, micro-invasive, and minimally invasive treatment (with or without restoration) options are available for primary and permanent teeth. Non-invasive strategies include oral hygiene instructions, dietary counseling, and personal as well as professional use of fluoridated products that reduce demineralization and increase re-mineralization. Micro-invasive procedures include the use of occlusal resin sealants and resin infiltrants, while minimally invasive strategies comprise those related to selective removal of caries tissues and placement of restorations. Deep caries management includes indirect pulp capping, while exposed pulp may be treated using direct pulp capping and partial or complete pulpotomy. The aim of the present study was to review available evidence on recommended preventive and restorative strategies for caries lesions in Latin American/Caribbean countries, and subsequently develop evidence-based recommendations for treatment options that take into consideration material availability, emphasize ways to adapt available treatments to the local context, and suggest ways in which dentists and health systems can adopt these treatments.

Microshear Bond Strength of Nanoparticle-Incorporated Conventional and Resin-Modified Glass Ionomer to Caries-Affected Dentin

The purpose of this study was to assess the influence of three different types of nanoparticles (silver (SNPs), titanium dioxide (TNPs), and zinc oxide (ZNPs)) on the microshear bond strength of conventional glass ionomer cement (CGIC) and resin-modified glass ionomer cement based on whether CGIC or RMGIC is used with four subgroups (based on the incorporation of SNPs, ZNPs, and TNPs in addition to a control subgroup) (n = 12) as follows: CGIC, CGIC + TNP, CGIC + ZNP, CGIC + SNP, RMGIC, RMGIC + TNP, RMGIC + ZNP, and RMGIC + SNP. After 24 hours, the μSBS of specimens was tested and the obtained data were analyzed using two-way ANOVA and Tukey's HSD test. The obtained results showed that the incorporation of TNPs in two glass ionomers was not statistically significant compared with the control subgroups (p > 0.05). In the first group, the highest and lowest mean μSBS were, respectively, observed in the CGIC + SNP subgroup and CGIC + ZNP subgroup. In the second group, RMGIC + ZNP and RMGIC + SNP, respectively, showed the highest and lowest mean μSBS compared to the other subgroups. According to the results, it can be concluded that TNPs can be incorporated into both CGIC and RMGIC without compromising the bond strength of glass ionomers. SNPs and ZNPs can be, respectively, added to CGICs and RMGICs to improve the bond strength of the restoration.

Effect of Cavity Disinfectants on Adhesion to Primary Teeth-A Systematic Review

Some authors have been proposing the use of cavity disinfectants in order to reduce, or even eliminate, the effect of the microorganisms present in a dental cavity before a restoration is placed. The aim of this study was to evaluate the effect of different cavity disinfectants on bond strength and clinical success of composite and glass ionomer restorations on primary teeth. The research was conducted using Cochrane Library, PubMed/MEDLINE, SCOPUS, and Web of Science for articles published up to February 2021. The search was performed according to the PICO strategy. The evaluation of the methodological quality of each in vitro study was assessed using the CONSORT checklist for reporting in vitro studies on dental materials. Sixteen in vitro studies and one in situ study fulfilled the inclusion criteria and were analyzed. Chlorhexidine was the most studied cavity disinfectant, and its use does not compromise dentin bonding. Sodium hypochlorite is a promising alternative, but more research on its use is required to clearly state that it can safely be used as a cavity disinfectant for primary teeth. Although other disinfectants were studied, there is a low-level evidence attesting their effects on adhesion, therefore their use should be avoided.

What is the best caries removal strategy for primary molars?

Aim This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to compare the efficacy of different caries removal techniques: complete caries removal (CCR), selective caries removal (SCR) and stepwise caries removal (SWR) for deep carious lesions in vital primary teeth.Data sources The design of this review followed the PRISMA guidance ( http://www.prisma-statement.org/ ). Relevant studies were identified using electronic databases (PubMed [Medline], Cochrane Library, EMBASE) and finally reference lists were screened. The US National Institutes of Health Trials Register (NIHTR; http://clinicaltrials.gov ) and World Health Organisation International Clinical Trials Registry Platform (WHO ICTRP; http://apps.who.int/trialsearch ) were used to help assess publication bias, as it was not possible to test funnel plot asymmetry. Duplicates were located and eliminated using EndNote X7 programme.Study selection To be included, studies had to be published RCTs comparing SCR or SWR with CCR as caries removal strategies for deep carious lesions in vital primary teeth. The outcomes were pulp exposure, pulpo-periodontal complications (clinical and radiological failures) and/or restorative failures. RCTs applying these caries removal techniques were excluded if one of the other trial arms did not involve caries removal (that is, Hall Technique, therapeutic sealing of cavity lesions). Initially, 1,374 potentially eligible articles were identified, out of which 15 (English or French language only) were selected for full-text screening, which included ten relevant references corresponding to eight studies.Data extraction and synthesis Two authors independently extracted data using a piloted data extraction sheet, with a third reviewer resolving any disagreements. The authors performed conventional intention-to-treat and per-protocol meta-analyses, and calculated odds ratios (ORs) as effect estimates in the random-effects model, using Revman5.Results The eight included RCTs were conducted between 1977 and 2018. They include 669 patients and 824 teeth, with follow-up ranging from four weeks to 24 months. Collective results showed reduced risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using United States Public Health Service (USPHS) criteria, after SCR was compared with CCR only in intention-to-treat analysis. However, when comparing the risk of clinical or radiographic failure of pulpo-periodontal complications, no difference was found between SCR, CCR or SWR.Conclusion The conclusions of the paper are that there is a significant decrease in pulp exposure risk with SCR and SWR in comparison with CCR. However, there is a need for further studies with less risk of bias powered to report on the long-term outcomes of pulpo-periodontal health and restoration longevity.

Clinical, radiographic, and histological evaluation of three different pulp-capping materials in indirect pulp treatment of primary teeth: a randomized clinical trial

OBJECTIVES

The aim of this randomized, controlled, three-arm parallel group, and double-blinded clinical trial was to evaluate the clinical, radiographic, and histopathological success of three different pulp-capping materials in one-stage indirect pulp treatment of primary teeth.

MATERIALS AND METHODS

The study included a total of 109 patients aged 5-9 years who had primary teeth with deep carious lesions and symptoms of reversible pulpitis. The teeth were divided into three groups according to the pulp-capping agents: (I) hard-setting calcium hydroxide (Dycal) (control group) (n = 36), (II) bioactive tricalcium silicate (Biodentine) (n = 37), and (III) resin-based tricalcium silicate (TheraCal LC) (n = 36). All the teeth were evaluated clinically and radiographically at 6, 12, 18, and 24 months postoperatively. A total of 23 primary mandibular second molars that were in their regular exfoliation period (24-40 months) were extracted and fixed in 10% formaldehyde solution. The specimens were evaluated histologically to assess the integrity of the odontoblastic layer, tertiary dentin formation quality of the dentin formed, severity of pulpitis, and other pulpal changes. Data were analyzed using Fisher's exact test, Pearson's chi-square test, and McNemar's test (p = 0.05).

RESULTS

At the end of the 24-month follow-up period, the clinical and radiographic success rates for Dycal, Biodentine, and TheraCal LC were 100%, 100%, and 93.3%, respectively, and there was no significant difference among the groups (p > 0.05). However, the TheraCal LC group was statistically unsuccessful when compared to the other groups with regard to the integrity of the odontoblastic layer, severity of pulpitis, and other pulpal changes in histological examination (p < 0.05).

CONCLUSION

Indirect pulp capping exhibited high clinical and radiographic success rates in the treatment of primary teeth regardless of the chosen pulp-capping agent. However, histological examination indicated that the pulp status was affected by the chosen capping material especially when selecting a resin-containing material such as TheraCal LC.

CLINICAL RELEVANCE

Resin-free calcium silicate-based materials appear to be more favorable in the indirect pulp treatment of primary teeth, particularly in young-age groups that require long-term success.

Two-Year Survival of High-Viscosity Glass Ionomer in Children with Molar Incisor Hypomineralization

OBJECTIVE

We assessed the clinical survival of a high-viscosity glass ionomer (HVGI) at the 2-year follow-up to restore molar incisors severely affected by hypomineralization after selective carious tissue removal (SCR). The null hypothesis tested was that there are no differences in the overall survival times in the categories of the variables of interest.

METHODS

A total of 134 fully erupted first molar incisors with hypomineralization, cavitated and with moderate-to-deep carious lesions without hypersensitivity or pain (MIH treatment need index 2a-c), were included in the study. HVGI (Equia Forte®; GC, Tokyo, Japan) restorations were applied after SCR to soft carious dentin. The follow-up lasted 2 years. The end point was defined as the absence of endodontic and restorative complications. Two-year, and 18-, 12-, and 6-month survival probabilities and standard errors were calculated using the Kaplan-Meier method. Survival probabilities according to patient gender, jaw, and lesion severity groups were compared using the log-rank test. Restorations were evaluated using the modified US Public Health Service criteria.

RESULTS

HVGI restorations showed cumulative survival probabilities of 95.5% at 6 months, 94% at 12 months, 87.5% at 18 months, and 87.5% at 24 months. Survival probabilities according to patient gender, jaw, and lesion severity groups were not statistically significantly different (p > 0.05). Therefore, the null hypothesis was accepted.

CONCLUSION

Following SCR, HVGI restoration provided moderate survival probabilities, suggesting that the SCR technique is effective.

Pulp Vitality and Longevity of Adhesive Restorations Are Not Affected by Selective Carious Removal: A Multicenter Clinical Trial

The aim of this multicenter randomized clinical trial was to evaluate the pulp vitality and survival rate of adhesive restorations performed on posterior deciduous teeth after non-selective (NSCR) or selective (SCR) carious tissue removal over 33 months. One hundred and seven children (average age 4-8 years, SD 1.4) with at least two active moderate cavitated lesions in dentin were included. Teeth were randomized and submitted to NSCR or SCR before composite resin restoration. Restorations were clinically and radiographically assessed at baseline, 6, 12, 18, 24, and 33 months by a blinded, trained, and calibrated operator in each center. The characteristics of the restorations were recorded according to FDI criteria and were considered as restorative failures when scores 4 or 5 were presented. Pulp vitality was measured by clinical and radiographic examinations, and those teeth that presented any signs or symptoms of irreversible pulpitis or pulp necrosis were considered as failure. Data were analyzed by a Cox regression model with shared frailty, considering two outcomes: pulp and restorative. A total of 278 restorations (137 after NSCR and 141 after SCR) were performed at baseline in four different centers and there was no loss in the follow-up period. Survival rate was 97.1 and 87.1% for pulp and for restorative outcome, respectively. The overall annual failure rate was 7%. There were no differences in the failure risk according to the treatment group, center, and all the clinical and demographic variables, regardless of outcome. Composite restorations of active moderate deep carious lesions performed on posterior primary teeth show satisfactory survival for restorative and pulp outcome after a 33-month follow-up, regardless of the technique executed for carious tissue removal.

Longevity of posterior composite restorations in children suffering from early childhood caries-results from a retrospective study

OBJECTIVES

This retrospective study aimed to evaluate health status as a new patient risk factor and analyze its influence on the survival of posterior composite restorations in patients with early childhood caries (ECC).

MATERIALS AND METHODS

Patients who received dental treatment of ECC under general anesthesia (GA) and attended at least one follow-up visit were included in this study. A total of 907 patient records were evaluated retrospectively through patient examination forms and panoramic radiographs. Kaplan-Meier survival probability analysis with log-rank test was used to assess the posterior composite restorations' longevity up to 24 months. Furthermore, risk factors were determined using Cox regression multivariate analysis.

RESULTS

A total of 5063 posterior composite restorations were assessed. Following the Cox regression analysis to determine the effect of risk factors on longevity of composite restorations, findings revealed that the survival probability of composite fillings was significantly lower in patients with systemic disease (p = 0.00). Filling materials were compared based on the survival probabilities and results were further discussed. There was no significant relationship between age, gender, and the survival of the restoration; however, the child's health status (p = 0.00) and caries risk status (p = 0.05) significantly affected survival. Moreover, the type of arch and pulp intervention influenced the restoration's survival.

CONCLUSION

Systemic disease has a detrimental influence over longevity of composite restorations. Therefore, considering the reduced survival rates of the composite restorations for children who have systemic disease, alternative non-invasive treatment options should be considered.

CLINICAL RELEVANCE

This study's novelty is the observation of drastically reduced survival of composite restorations in children with systemic disease.

Dentists' decisions for deep carious lesions management in primary teeth

BACKGROUND

Questionnaire surveys have been undertaken worldwide to investigate practices and knowledge related to deep carious lesion (DCL) management in permanent teeth, and there is a lack of data in primary teeth.

AIM

A cross-sectional questionnaire survey was undertaken to describe the management strategies for DCL of vital primary teeth, focusing on the different caries removal techniques, among dentists practicing pediatric dentistry (DPPDs) in France. Their behavior was compared to members one registered to European Academy of Pediatric Dentistry (EAPD).

DESIGN

A questionnaire was electronically administrated (2018-2019) to members of the Collège des Enseignants en Odontologie Pédiatrique (CEOP), the Société Française d'Odontologie Pédiatrique (SFOP), and the EADP. Descriptive and statistical analyses were performed.

RESULTS

Response rate was, respectively, for CEOP, SFOP, and EAPD about 74%, 29%, and 15%. About half of the respondents (53%) would perform a complete caries removal into one step when 12% would indicate a stepwise technique: 68% of the DPPDs practicing in France would perform complete caries removal in one step when the preferred option in the other EAPD members was the selective excavation (44%) (P < .001).

CONCLUSIONS

Complementary education of French dentists in the domain of caries management appears necessary regarding current recommendations.

How to Intervene in the Caries Process: Dentin Caries in Primary Teeth

For an ORCA/EFCD consensus, this review systematically assessed available evidence regarding interventions performed and materials used to manage dentin carious lesions in primary teeth. A search for systematic reviews (SRs) and randomized clinical trials (RCTs) with a follow-up of at least 12 months after intervention was performed in PubMed, LILACS, BBO, and the Cochrane Library. The risk of bias tool from the Cochrane Collaboration and the PRISMA Statement were used for assessment of the included studies. From 101 screened articles, 2 SRs and 5 RCTs, which assessed the effectiveness of interventions in terms of pulp vitality and success of restoration, and 10 SRs and 1 RCT assessing the success of restorative materials were included. For treatments involving no carious tissue removal, the Hall technique showed lower treatment failure for approximal carious lesions compared to complete caries removal (CCR) and filling. For the treatment of deep carious lesions, techniques involving selective caries removal (SCR) showed a reduction in the incidence of pulp exposure. However, the benefit of SCR over CCR in terms of pulp symptoms or restoration success/failure was not confirmed. Regarding restorative materials, preformed metal crowns (PMCs) used to restore multisurface lesions showed the highest success rates compared to other restorative materials (amalgam, composite resin, glass ionomer cement, and compomer), and in the long term (12-48 months) these were also less likely to fail. There is limited evidence supporting the use of PMCs to restore carious lesions with single cavities. Among nonrestorative options, silver diammine fluoride was significantly more effective in arresting caries than other treatments for treating active carious lesions of different depths. Considerable heterogeneity and bias risk were observed in the included studies. Although heterogeneity observed among the studies was substantial, the trends were similar. In conclusion, less invasive caries approaches involving selective or no caries removal seem advantageous in comparison to CCR for patients presenting with vital, symptomless, carious dentin lesions in primary teeth. There is evidence in favor of PMCs for restoring multisurface carious lesions in primary molars.

Shortening of etching time of the dentin in primary teeth restorations: a randomized clinical trial

The aim of this study was to investigate the influence of shortening of etching time for dentin on the restoration survival after selective carious tissue removal in primary molars. This two-arm randomized clinical trial included sixty-two subjects (5-8 year-old) and 100 primary molars presenting moderate dentin carious lesions on occlusal surface. The sample was randomly assigned into groups previously to adhesive application (Adper Single Bond 2; 3M ESPE): etching time recommended by manufacturer (15 s) or reduced (7 s). Resin composite (Filtek Bulk Fill Posterior Restorative; 3M ESPE) was inserted in a single increment for all restorations. Restorations were evaluated at 1, 6, 12, and 18 months using FDI criteria. Survival estimates for restorations' longevity were evaluated with Kaplan-Meier method. Multivariate Cox regression analysis with shared frailty was used to assess the factors associated with failures (p < 0.05). The etching time did not influence the restorations' survival (HR 0.35 95%CI 0.11-1.12; p = 0.06). Mean estimated time of survival was 17.6 months (95%CI, 17.2-17.9). The survival rates at the 18-month follow-up were 75.7% and 91.4% (AFR: 16.9% and 5.7%) when primary dentin was acid etched for 15 and 7 s, respectively (log-rank p = 0.06). In conclusion, the etching time for dentin did not influence the clinical behavior of adhesives restorations. However, there was a tendency for better clinical outcome when using etching time of 7 s.

Caries removal strategies for deep carious lesions in primary teeth: Systematic review

The study aimed to compare the efficacy of three caries removal techniques-complete caries removal (CCR), selective caries removal (SCR), and stepwise caries removal (SWR)-for deep carious lesions in vital temporary teeth by conducting a systematic review and meta-analysis of randomized controlled trials (RCTs). Electronic databases (PubMed [MEDLINE], Cochrane Library, EMBASE) were searched for corresponding references up to 31 May 2019. Possible outcomes were pulp exposure, pulpo-periodontal complications, or restorative failures. Three reviewers independently selected studies, extracted data, and assessed the risk of bias using RoB 2. Meta-analyses for intention-to-treat and per-protocol scenarios were performed using Revman5. Of 1374 potentially eligible articles, ten relevant references corresponding to eight studies were included. Pooled results showed decreased risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using USPHS criteria, after SCR compared with CCR only in intention-to-treat analysis. Risk of clinical or radiographic failure of pulpo-periodontal complications was unchanged when compared with SCR and CCR or SWR. SCR and SWR may result in lower pulp exposure risk than CCR. RCTs with lower risk of bias, higher power, and longer follow-up are required to choose between these three caries removal techniques for deep carious lesions in vital temporary teeth.

Restorations after selective caries removal: 5-Year randomized trial

OBJECTIVE

To compare the survival of restorations placed in deep caries lesions after selective caries removal to soft dentin (SCRSD) over a 5-year period. A secondary aim was to investigate whether the material (amalgam or resin composite) affected the survival of restorations.

METHODS

This study used data derived from a multicenter randomized controlled clinical trial (Clinical trials registration NCT00887952). Inclusion criteria were: patients with permanent molars presenting occlusal or proximal deep caries lesions (≥1/2 of the dentin thickness on radiographic examination), positive response to a cold test, absence of spontaneous pain, negative sensitivity to percussion, and absence of periapical lesions. The teeth were randomized into SCRSD and restoration in a single visit or stepwise excavation (SW). Each of these groups was divided according to the filling material: amalgam (AM) or resin composite (RC). Survival analyses were performed to estimate therapy success rates over 5 years (adjusted Weibull regression model).

RESULTS

172 restorations were evaluated, 95 from SCRSD group and 77 from SW group, being 61 AMG and 111 RC. The 5-year survival analysis showed similar success rates for SW (76 %) and SCRSD (79 %) as well as for AM and RC (p > 0.05).

CONCLUSION

This study showed that, after a 5-year follow-up period, the presence of decayed tissue beneath restorations in deep caries lesions did not seem to affect restoration survival. Amalgam and resin composite restorations had similar survival rates, irrespective of the caries removal technique used - SCRSD or SW.

CLINICAL SIGNIFICANCE

Selective caries removal to soft dentin can be used in the management of deep caries to avoid pulp exposure and preserve tooth structure without affecting restoration longevity.

A Primary Care Randomized Controlled Trial of Hall and Conventional Restorative Techniques

OBJECTIVES

To investigate treatment outcomes of different restorative techniques undertaken by dental therapists for primary molar carious lesions in a sample of children in New Zealand primary care.

METHODS

This was a randomized controlled trial with children aged 3 to 8 y in New Zealand's Whanganui region. Children meeting inclusion criteria were randomly allocated to treatment with either the Hall technique (HT), in which a stainless-steel crown (SSC) is placed without any carious tissue removal or tooth preparation, or a non-Hall conventional restorative approach (NHT), including tooth preparation with selective carious tissue removal; this included SSC, amalgam, composite, or glass ionomer cement (GIC) restorations. Restorative outcomes after 12 and 24 mo were categorized as success, minor failure, or major failure.

RESULTS

Of the 295 eligible children, 149 and 146 were allocated to the HT and NHT groups, respectively, with a total of 570 carious primary molars treated by 13 dental therapists. The participant follow-up rates at 12 and 24 mo were 95% and 91%. SSCs were the most commonly used restoration in the NHT group (60%), followed by GIC (28%). SSCs were the most successful restorations regardless of whether they were placed with the HT or NHT, with success rates of 89% and 92% at 12 mo and 85% and 86% at 24 mo. In the NHT group, the treatment material was a predictor of minor failure at 12 and 24 mo, with significantly more failures with GICs.

CONCLUSIONS

SSCs placed by dental therapists are a highly successful restoration for the primary dentition, regardless of whether they are placed with the HT or conventionally. The high failure rate of glass ionomer restorations means that they cannot be recommended for widespread use in New Zealand primary care (Australian New Zealand Clinical Trials Registry, ACTRN12614000844640).

KNOWLEDGE TRANSFER STATEMENT

The findings of this study can be used by policy makers and clinicians when deciding on which materials and which approach to use to maximize success and to minimize retreatment rates when providing restorative treatment for carious primary molars in children's primary oral health care. Results also suggest that undertaking research in the primary care setting may enhance translation of new knowledge and techniques into clinicians' hands.

Selective removal compared to complete removal for deep carious lesions

INTRODUCTION

Dental caries have been conventionally managed by non-selective removal of carious tissue (total complete removal); however, the adverse effects of this procedure have promoted the use of conservative caries removal techniques (selective removal), but there is still controversy regarding its effectiveness.

METHODS

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified seven systematic reviews including seven studies overall, of which all were randomized trials. We concluded that selective caries removal may decrease the need for root canal treatment and the risk of pulp exposure in teeth with deep caries, but the certainty of the evidence is low. It is not clear whether the selective removal of caries reduces the risk of appearance of signs and symptoms of pulp disease and the risk of restorations failure, as the certainty of the evidence is very low.

Survival of composite restorations after selective or total caries removal in primary teeth and predictors of failures: A 36-months randomized controlled trial

OBJECTIVES

The aim of this study was to assess the survival of composite restorations after selective (SCR) or total caries removal (TCR) and determine predictors of failures after 36 months.

METHODS

120 teeth with deep occlusal or occlusal-proximal carious lesions were randomly divided into control (TCR; n = 54; 69% Class II) and test (SCR; n = 66; 63% Class II) groups. Clinical evaluation was applied using the USPHS criteria, and the presence of Charlie or Delta scores at the marginal integrity were considered as a failure.

RESULTS

The overall survival rate of restorations was 68% after 36 months, 81% for TCR and 57% for SCR (p = 0.004). The multivariable Cox Regression model demonstrated that restorations performed after SCR had 3.44 times greater probability of failure compared to TCR (p = 0.006). The other two predictors for failure of restorations were teeth with Class II cavities (hazard ratio = 3.3) and children with gingival bleeding over 20% (hazard ratio = 2.5).

CONCLUSIONS

Performing composite restorations after SCR in primary teeth had success rate significantly lower than restorations performed after TCR. Complex cavities and worst patient´s oral hygiene were found to be predictors of failure of restorations.

CLINICAL SIGNIFICANCE

Although SCR has been demonstrating high rates of pulp preservation, clinicians should consider that composite restorations fail in a higher frequency compared to TCR in primary teeth and, in some circumstances, may be preferable in terms of restoration longevity.

Does selective carious tissue removal of soft dentin increase the restorative failure risk in primary teeth?: Systematic review and meta-analysis

BACKGROUND

The authors conducted a systematic review of randomized controlled trials comparing the risk of experiencing restoration failure in primary teeth after complete and selective carious tissue removal of soft dentin.

METHODS

The authors searched electronic databases (PubMed [MEDLINE], Scopus, Cochrane Central Register of Controlled Trials) and the ClinicalTrials.gov Web site with manual searching and cross-referencing for trials reporting restoration failure after follow-up of 6 months or longer. Two reviewers independently selected studies, extracted data, and assessed the risk of bias and quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. The authors performed intention-to-treat and per-protocol meta-analyses and calculated odds ratios (OR) as effect estimates in the random-effects model.

RESULTS

From 327 potentially eligible studies, the authors selected 23 for full-text screening and included 4. Results showed increased risk of experiencing restoration failure (intention-to-treat analysis, OR [95% confidence interval] 1.74 [1.01 to 3.00], and per-protocol analysis, OR [95% confidence interval] 1.79 [1.04 to 3.09]) after selective carious tissue removal of soft dentin. The risk of bias was high, and the quality of evidence was low.

CONCLUSIONS

Selective carious tissue removal of soft dentin may increase the risk of experiencing restoration failure in primary teeth. However, the evidence level is insufficient for definitive conclusions.

PRACTICAL IMPLICATIONS

Patients with restorations performed after selective carious tissue removal of soft dentin should have shorter recall visit intervals to evaluate the restorations' quality and control caries disease, allowing for more conservative approaches, such as repair, in cases of defective restorations.

Effect of Different Liners on Pulpal Outcome after Partial Caries Removal: A Preliminary 12 Months Randomised Controlled Trial

Aim: The aim of this double-blinded parallel randomised controlled trial was to compare the effect of different liners on 12-month pulp health outcomes after partial caries removal (PCR) with composite restorations in permanent molars. Methods: The study was registered at clinicaltrials.gov with registration No. NCT0328695 and conducted in the Department of Conservative dentistry and Endodontics, Post Graduate Institute of Dental Sciences Rohtak with no external financial support. One hundred and ninety-eight participants (116 males, 82 females and age 14–54 years) with vital permanent mature mandibular molars having deep caries involving two-thirds or more of dentin were randomised to calcium hydroxide (CH), resin-modified GIC (RMGIC) and no liner (DC) groups after PCR. After a follow-up time of 12 months, success was defined as positive response to pulp sensibility and absence of periapical alterations. Results: Categorical variables were compared using chi-square test. Two analytical approaches were used, such as intention-to-treat and per-protocol approach. Success rates in per-protocol approach were 96.8, 96.5, and 94.6% for CH, RMGIC and DC groups, respectively with no significant difference between 3 groups (p = 0.811). None of the baseline variables had any significant influence on the treatment success. Conclusion: Partial caries excavation has a high success rate to treat deep carious lesions in permanent teeth after 12 months of follow-up, indicating that the retention of carious dentin does not interfere with pulp vitality or restoration survival. Also, the success of the treatment is independent of the lining material used over the demineralized dentin.

Repair increases the survival of failed primary teeth restorations in high-caries risk children: a university-based retrospective study

OBJECTIVES

We investigated factors associated with failure of adhesive restorations in primary teeth and whether repair may increase the survival of failed restorations placed in high-caries risk children.

MATERIALS AND METHODS

The sample comprised children who attended a university dental service to perform restorative treatment in primary teeth. Data were collected retrospectively from clinical records to assess the longevity of restorations. The outcomes were calculated in two levels: "Success" (Level 1)-when any re-intervention was considered as failure; "Survival" (Level 2)-when repaired restorations were considered clinically acceptable. The Kaplan-Meier survival test was used to analyze the longevity of restorations. Multivariate Cox regression with shared frailty was used to assess factors associated with failures (p < 0.05).

RESULTS

A total of 584 primary teeth restorations (178 patients) were included in the analysis. The longevity of restorations up to 36 months (Level 1) was 34.8% (AFR 29.6%). Multi-surface restorations showed significantly more failures than single-surface ones (HR 1.69; 95% CI 1.18, 2.41), and endodontically treated teeth presented more failures compared to vital teeth (HR 2.22; 95% CI 1.35, 3.65). There was an increase in restoration survival when repair was not considered as failure (p < 0.001). The survival of repaired restorations (Level 2) reached 43.7% (AFR 24.1%).

CONCLUSIONS

Adhesive restorations placed in primary teeth of high-caries risk children showed restricted longevity; however, the repair of failed restorations has increased its survival over time.

CLINICAL RELEVANCE

Repair is a more conservative and technically simple procedure that increases the survival of failed restorations in primary teeth.

Selective Removal of Necrotic Dentin in Primary Teeth Using Laser Irradiation: One-Year Clinical Evaluation of Composite Restorations

Introduction: This study aimed to evaluate the child's salivary cortisol levels, clinical performance and marginal adaptation of restorations after selective removal of necrotic dentin in primary teeth using Er: YAG laser irradiation. Methods: A double-blind clinical study was performed in children at 7-10 years. Children who had at least 2 teeth with carious lesions involving the occlusal and proximal surfaces of primary molars counterparts were selected. Removal of necrotic dentin was performed by 2 methods: Er: YAG laser irradiation and bur-preparation. Cortisol levels (n =24) was evaluated by ELISA. Clinical analysis (n =20) was performed after the restorations polish, 6 and 12 months after restorative procedure using United States Public Health Service (USPHS) method and photographs. Scanning electron microscopy (SEM) was used to analyz the marginal gap formation (n =20). The analysis of the data was performed by 95% confidence interval, Shapiro-Wilk test, Friedman and Wilcoxon post hoc tests (α =5%). Results: Cortisol levels were higher during selective removal of necrotic dentin, regardless of the method used (P>0.05). After 12 months, there was no evidence of the difference in the restorations performed on cavities prepared by both methods. SEM analysis revealed that the laser-irradiated teeth showed 10% of gaps in the full extent of restoration. For bur-prepared teeth, 20% of gaps were found at the cavosurface margin. Conclusion: The salivary cortisol levels on children that received Er: YAG laser irradiation for removal the necrotic dentin was similar to the control group. Class II restorations evaluated after 1 year period did not suffer interference by the use of Er: YAG laser irradiation.

Clinical and Radiographic Success of Selective Caries Removal to Firm Dentin in Primary Teeth: 18-Month Follow-Up

The selective caries removal is increasingly spreading in daily clinical practice because this minimally invasive technique treats deep carious lesion and decreases the risk of pulp exposure. This case report was aimed at describing the selective removal to firm dentin on the primary mandibular left first molar of a girl aged 7 years and 6 months. The Mineral Trioxide Aggregate (MTA Angelus™) was used as liner, and the tooth was definitively restored with resin-modified glass ionomer cement (Vitremer™). The clinical and radiographic following-up was performed at 6, 12, and 18 months after treatment. The treatment showed satisfactory results after 18-month following-up, suggesting that this minimally invasive approach for carious lesion removal can replace the total removal, when properly indicated. Notwithstanding, further randomized clinical trials with longer following-up periods are still necessary.

Effect of selective carious tissue removal on biomechanical behavior of class II bulk-fill dental composite restorations

OBJECTIVES

This study aimed to develop a method to induce carious lesions in the pulpal floor dentin of a class II cavity preparation, and to determine the effects of this carious lesion on the biomechanical behavior of the dental composite restoration.

METHODS

The pulpal floor dentin of class I cavities in sound third molars were demineralised with acetic acid for 35days followed by a 7-day exposure to pooled human saliva biofilm and demineralization was verified by micro-CT. Subsequently, the proximal walls were removed forming a class II cavity and the caries lesion was left intact or was completely removed prior to restoration with a bulk-fill dental composite (n=10). Cuspal deflection was assessed by strain-gauge and micro-CT imaging. The presence of enamel cracks was assessed by transillumination before and after restoration, and again after 1,200,000 cycles of mechanical fatigue in a chewing simulator. Finally, resistance to fracture by axial compressive loading and failure mode was determined. Data were analyzed by 2-way repeated measures ANOVA, Fisher's exact test, and t-test (α=0.05).

RESULTS

The presence of carious lesions had no significant effect upon cuspal deflection, formation of enamel cracks, and fracture strength of the dental composite restorations. The restorative procedure increased the number of enamel cracks, which was not affected by mechanical cycling.

SIGNIFICANCE

Maintaining carious lesions does not affect the biomechanical behavior of class II restorations performed with bulk-fill dental composite.

Restorations in primary teeth: a systematic review on survival and reasons for failures

BACKGROUND

Several restorative materials with specific indications are used for filling cavities in primary teeth.

AIM

To systematically review the literature in order to investigate the longevity of primary teeth restorations and the reasons for failure.

DESIGN

Electronic databases were screened, and eligible studies were hand-searched to find longitudinal clinical studies evaluating the survival of restorations (class I, class II, and crown) placed with different materials in primary teeth with at least one year of follow-up.

RESULTS

Thirty-one studies were included, and a high bias risk was observed. Overall, 12,047 restorations were evaluated with 12.5% of failure rate. A high variation on annual failure rate (AFR) was detected (0-29.9%). Composite resin showed the lowest AFRs (1.7-12.9%). Stainless steel crowns (SSC) had the highest success rate (96.1%). Class I restorations and restorations placed using rubber dam presented better AFR. The main reason for failure observed was secondary caries (36.5%).

CONCLUSIONS

An elevated number of failures were observed due to recurrent caries, highlighting the need for professionals to work with a health-promoting approach. The high variation on failure rate among the materials can be due to children's behavior during the procedure, which demands short dental appointments and a controlled environment.

Survival and Associated Risk Factors of Selective Caries Removal Treatments in Primary Teeth: A Retrospective Study in a High Caries Risk Population

Objective: The aim of this retrospective study was to analyze the survival probability of selective caries removal (SCR) treatments in the primary teeth of children with high caries experience and factors potentially associated with treatment failure. Methods: The sample included SCR treatments conducted in anterior and posterior teeth without sedation or general anesthesia among children attending a university dental service. Kaplan-Meier survival analysis was used to estimate the longevity of restorations and multivariate Cox regression with shared frailty was used to assess risk factors. Results: A total of 284 SCR treatments in 88 children (aged 5.2 ± 1.91 years) with high caries experience (mean dmft/DMFT = 11.1 ± 5.04) were analyzed. The 3-year survival reached 48.8%, with an annual failure rate of 21.2%. Restorative failures (n = 60) were found more frequently compared to pulp complications (n = 12). SCR performed in anterior primary teeth were more prone to failure (hazard ratio = 3.6, 95% CI: 1.94; 6.71). Patients with a higher amount of visible plaque experienced more failures in SCR treatments (hazard ratio 3.0, 95% CI:1.27; 7.07). Conclusions: In this retrospective study, SCR showed restricted survival when compared to other prospective clinical trials. Patient-related factors, especially the young age and high caries experience of the children, may represent a challenge for restoration survival. Regardless of the caries removal technique or restorative material, cariogenic biofilm has a negative effect on the survival of restorations, probably by acting directly on material deterioration and, particularly, on the development of new caries lesions of rapid progression.

Annual review of selected scientific literature: Report of the committee on scientific investigation of the American Academy of Restorative Dentistry

STATEMENT OF PROBLEM

It is clear the contemporary dentist is confronted with a blizzard of information regarding materials and techniques from journal articles, advertisements, newsletters, the internet, and continuing education events. While some of that information is sound and helpful, much of it is misleading at best.

PURPOSE

This review identifies and discusses the most important scientific findings regarding outcomes of dental treatment to assist the practitioner in making evidence-based choices. This review was conducted to assist the busy dentist in keeping abreast of the latest scientific information regarding the clinical practice of dentistry.

MATERIAL AND METHODS

Each of the authors, who are considered experts in their disciplines, was asked to peruse the scientific literature published in 2015 in their discipline and review the articles for important information that may have an impact on treatment decisions. Comments on experimental methodology, statistical evaluation, and overall validity of the conclusions are included in many of the reviews.

RESULTS

The reviews are not meant to stand alone but are intended to inform the interested reader about what has been discovered in the past year. The readers are then invited to go to the source if they wish more detail.

CONCLUSIONS

Analysis of the scientific literature published in 2015 is divided into 7 sections, dental materials, periodontics, prosthodontics, occlusion and temporomandibular disorders, sleep-disordered breathing, cariology, and implant dentistry.

Alternative approach for carious tissue removal in primary teeth

BACKGROUND

Minimally-invasive techniques for the management of carious dental tissue has been well documented. This study aimed to report on the clinical and radiographic response after partial caries removal on left mandibular primary second molar.

CASE REPORT

A 6-year-old boy sought treatment because of pain in the left mandibular primary second molar. The tooth had a deep caries lesion on the occlusal surface, with loss of enamel structure and dentine proximity with the pulp confirmed by periapical radiograph. According to the clinical and radiographic diagnosis, partial caries removal was the treatment of choice. Calcium hydroxide cement was used as pulp capping material.

FOLLOW-UP

In this case report, partial caries removal showed satisfactory clinical and radiographic outcomes after 18-month following-up period.

CONCLUSION

Partial caries removal only is applicable when properly indicated. However, further clinical studies with longer following-up periods are necessary.