Longevity of direct restorations in Dutch dental practices. Descriptive study out of a practice based research network

Diagnostic Strategies for Restorations Management: A 70-Month RCT

We aimed to evaluate the impact of 2 visual diagnostic strategies for assessing secondary caries and managing permanent posterior restorations on long-term survival. We conducted a diagnostic cluster-randomized clinical trial with 2 parallel groups using different diagnostic strategies: (C+AS) based on caries assessment, marginal adaptation, and marginal staining aspects of the FDI (World Dental Federation) criteria and (C) based on caries assessment using the Caries Associated with Restorations or Sealants (CARS) criteria described by the International Caries Detection and Assessment System (ICDAS). The treatment for the restoration was conducted based on the decision made following the allocated diagnostic strategy. The restorations were then clinically reevaluated for up to 71 mo. The primary outcome was restoration failure (including tooth-level failure: pain, endodontic treatment, and extraction). Cox regression analyses with shared frailty were conducted in the intention-to-treat population, and hazard ratios (HRs) and 95% confidence intervals (95% CIs) were derived. We included 727 restorations from 185 participants and reassessed 502 (69.1%) restorations during follow-up. The evaluations occurred between 6 and 71 mo. At baseline, C led to almost 4 times fewer interventions compared with the C+AS strategy. A total of 371 restorations were assessed in the C group, from which 31 (8.4%) were repaired or replaced. In contrast, the C+AS group had 356 restorations assessed, from which 113 (31.7%) were repaired or replaced. During follow-up, 34 (9.2%) failures were detected in the restorations allocated to the C group and 30 (8.4%) allocated to the C+AS group in the intention-to-treat population, with no significant difference between the groups (HR = 0.83; 95% CI = 0.51 to 1.38; P = 0.435, C+AS as reference). In conclusion, a diagnostic strategy focusing on marginal defects results in more initial interventions but does not improve longevity over the caries-focused strategy, suggesting the need for more conservative approaches.

Challenges in conducting clinical research in primary care dentistry

The integration of dentistry into primary health care is crucial for promoting patient well-being. However, clinical studies in dentistry face challenges, including issues with study design, transparency, and relevance to primary care. Clinical trials in dentistry often focus on specific issues with strict eligibility criteria, limiting the generalizability of findings. Randomized clinical trials (RCTs) face challenges in reflecting real-world conditions and using clinically relevant outcomes. The need for more pragmatic approaches and the inclusion of clinically relevant outcomes (CROs) is discussed, such as tooth loss or implant success. Solutions proposed include well-controlled observational studies, optimized data collection tools, and the integration of artificial intelligence (AI) for predictive modelling, computer-aided diagnostics and automated diagnosis. In this position paper advocates for more efficient trials with a focus on patient-centred outcomes, as well as the adoption of pragmatic study designs reflecting real-world conditions. Collaborative research networks, increased funding, enhanced data retrieval, and open science practices are also recommended. Technology, including intraoral scanners and AI, is highlighted for improving efficiency in dental research. AI is seen as a key tool for participant recruitment, predictive modelling, and outcome evaluation. However, ethical considerations and ongoing validation are emphasized to ensure the reliability and trustworthiness of AI-driven solutions in dental research. In conclusion, the efficient conduct of clinical research in primary care dentistry requires a comprehensive approach, including changes in study design, data collection, and analytical methods. The integration of AI is seen as pivotal in achieving these objectives in a meaningful and efficient way.

Partial glass-ceramic posterior restorations with margins beyond or above the cemento-enamel junction: An observational retrospective clinical study

PURPOSE

This observational retrospective clinical study aimed to investigate the survival and success rates of partial indirect lithium disilicate restorations with margins extending above or beyond the cementoenamel junction (CEJ).

METHODS

The study included patients who underwent partial indirect lithium disilicate restorations with immediate dentin sealing (IDS) between January 2008 and October 2018. All the restorations were placed in a single general dental practice following a standardized protocol. The impact of various predictive variables on the survival rates was assessed. Moreover, modified United States Public Health Service (USPHS) criteria were used to evaluate the survival quality.

RESULTS

Totally 1146 partial indirect lithium disilicate restorations in 260 patients were evaluated over an average period of 7.5 years. The cumulative survival and success rates were 97.3% and 95.3%, respectively. Margins extending beyond the cemento-enamel junction did not increase the risk of success or survival failure (P > 0.05). Patients with a high risk of caries, male sex, or non-vital teeth had a significantly higher risk of restoration failure (P < 0.05). Restorations with longer clinical service times exhibited marginally lower clinical quality (P < 0.001).

CONCLUSIONS

Partial indirect glass-ceramic restorations demonstrated survival and success rates of 97.3% and 95.3%, respectively, over an extended period. However, a higher risk of restoration failure existed in patients with a high caries risk for (pre)molars that had undergone endodontic treatment and in males. In terms of the risk of success or survival failure, comparable results were obtained for the positions of the restoration margin in relation to the cemento-enamel junction.

Longevity of composite restorations in posterior teeth placed by dental students: a 12-year retrospective study

OBJECTIVES

To evaluate the longevity of resin composite restorations placed in posterior teeth by dental students, using data from electronic records from 2008 to 2019.

MATERIALS AND METHODS

Demographic (gender and age) and clinical variables (dental group, position in dental arch, and the number of restored surfaces) were evaluated. The 5-year follow-up was assessed according to the day the restoration was placed. Kaplan-Meier curves were generated to calculate the annual failure rate. Data were analyzed by Chi-Square, Kruskal-Wallis, and Mann-Whitney tests (α = 0.05).

RESULTS

In total, 3.883 records relative to return periodicity were analyzed. The final sample consisted of 900 restorations from 479 patients. The majority were females, aged between 31 and 60. In total, 256 failures were reported (success rate = 78%), showing an annual failure rate of 2.05%. The main reasons for failures were restoration replacement (55.5%), endodontics (21.9%), prosthetics (14.5%) and extraction (8.2%). There was a higher risk of failure in restorations involving three or more surfaces (p = 0.000) and in patients over 60 years (p < 0.001). In females (p = 0.030), molars (p = 0.044), and maxillary teeth (p = 0.038) failed in a shorter time.

CONCLUSIONS

Resin composite restorations placed in permanent posterior teeth by dental students had high survival rates. The main reason for failure was the replacement of restorations. The age group and the number of restored surfaces significantly affected the success of the restorations.

CLINICAL RELEVANCE

The electronic health records over 12 years showed that 78% of the resin restorations in posterior teeth placed by dental students were successful for a minimum of five years.

Biomechanical behavior of molars restored with direct and indirect restorations in combination with deep margin elevation

STATEMENT OF PROBLEM

The existing knowledge is insufficient for comprehending the fatigue survival and fracture resistance of molars that have deep approximal direct and indirect restorations, whether with or without deep margin elevation (DME).

PURPOSE

The aim of this laboratory and in silico study is to investigate the fatigue survival, fracture strength, failure pattern and tooth deformation of molars restored with DME in combination with a direct or indirect restoration.

MATERIAL AND METHODS

This study utilized 45 extracted sound human molars, divided into three groups (n = 15). Standardized 100% inter-cuspal inlay preparations were performed, extending 2 mm below the CEJ and immediate dentin sealing (IDS) was applied. Group 1 (Co_1) was restored with direct composite; Group 2 (Hyb_2) with a 2 mm DME of direct composite and a glass-ceramic lithium disilicate restoration; Group 3 (Cer_3) a glass-ceramic lithium disilicate restoration. All specimens were exposed to a fatigue process involving thermal-cyclic loading (50N for 1.2 × 106 cycles at 1.7 Hz, between 5 and 55 °C), if teeth survived, they were fractured using a load-to-failure test and failure types were analyzed. Finite element analysis (FEA) was conducted to assess tooth deformation and tensile stress in the restorations. Statistical evaluation of fracture strength was conducted using the Kruskal-Wallis test. Fisher's exact test was utilized to analyze the fracture types and repairability. A statistical significance level of α < 0.05 was set for all analyses.

RESULTS

All specimens successfully withstood the fatigue testing procedure, and no statistically significant differences in fracture strength were observed among the three groups (P > 0.05). The Fisher's exact test indicated a significant association between the restorative material and fracture type (F2 = 18.315, df = 2, P = 0.004), but also for repairability (F2 = 13.725, df = 2, P = 0.001). Crown-root fractures were significantly more common in the Cer_3 group compared to the Co_1 group (P = 0.001) and the Co_1 group had significantly more repairable fractures (F2 = 13.197, df = 2, P = 0.001). FEA revealed comparable outcomes of deformation among models and higher maximum tensile stress on models with higher frequency of catastrophic failures.

CONCLUSIONS

All tested restoration materials exhibited comparable fatigue survival and fracture strength in this laboratory and in silico study. However, it is important to recognize the potential for more severe and irreparable fractures when opting for deeply luted glass-ceramic inlay restorations in clinical practice. In such cases, it would be prudent to consider the alternative option being a direct composite approach, because of its more forgiving fracture types and repairability.

CLINICAL IMPLICATIONS

Molars with deep approximal direct and indirect restorations, whether with or without DME, are comparable in their fatigue survival and fracture resistance to withstand intra-oral forces. Deep direct restorations exhibit more repairable fractures compared to deeply luted glass-ceramics.

Survival analysis of posterior composite restorations in National Dental PBRN general dentistry practices

OBJECTIVE

Quantify the survival of posterior composite restorations (PCR) placed during the study period in permanent teeth in United States (US) general dental community practices and factors predictive of that survival.

METHODS

A retrospective cohort study was conducted utilizing de-identified electronic dental record (EDR) data of patients who received a PCR in 99 general dentistry practices in the National Dental Practice-Based Research Network (Network). The final analyzed data set included 700,885 PCRs from 200,988 patients. Descriptive statistics and Kaplan Meier (product limit) estimator were performed to estimate the survival rate (defined as the PCR not receiving any subsequent treatment) after the first PCR was observed in the EDR during the study time. The Cox proportional hazards model was done to account for patient- and tooth-specific covariates.

RESULTS

The overall median survival time was 13.3 years. The annual failure rates were 4.5-5.8 % for years 1-5; 5.3-5.7 %, 4.9-5.5 %, and 3.3-5.2 % for years 6-10, 11-15, and 16-20, respectively. The failure descriptions recorded for < 7 % failures were mostly caries (54 %) and broken or fractured tooth/restorations (23 %). The following variables significantly predicted PCR survival: number of surfaces that comprised the PCR; having at least one interproximal surface; tooth type; type of prior treatment received on the tooth; Network region; patient age and sex. Based on the magnitude of the multivariable estimates, no single factor predominated.

CONCLUSIONS

This study of Network practices geographically distributed across the US observed PCR survival rates and predictive factors comparable to studies done in academic settings and outside the US.

CLINICAL SIGNIFICANCE

Specific baseline factors significantly predict the survival of PCRs done in US community dental practices.

Clinical longevity of direct and indirect posterior resin composite restorations: An updated systematic review and meta-analysis

OBJECTIVES

To answer the PICO(S) question: Is there a difference in clinical longevity between direct and indirect resin composite restorations placed on permanent posterior teeth?

DATA

Randomized controlled clinical trials (RCTs) investigating direct and indirect resin composite restorations in posterior permanent teeth were considered.

SOURCES

Several electronic databases were searched, with no language or date restrictions. The revised Cochrane Collaboration's tool for assessing risk of bias (RoB-2) was used to analyze the studies; meta-analyses were run and the certainty of evidence was assessed by the GRADE tool. A subgroup meta-analysis was performed for resin composite restorations placed on posterior worn dentition.

STUDY SELECTION

Twenty-three articles were included in qualitative synthesis, while 8 studies were used for meta-analyses. According to the RoB-2 tool, 5 studies were ranked as "low risk", 7 had "some concerns", while 11 papers were rated as "high risk" of bias. There were no statistically significant differences in short-term (p = 0.27; RR=1.54, 95% CI [0.72, 3.33]), medium-term (p = 0.27; RR=1.87, 95% CI [0.61, 5.72]) and long-term longevity (p = 0.86; RR=0.95, 95% CI [0.57, 1.59]). The choice of restorative technique had no influence on short-term survival of resin composite restorations placed on worn dentition (p = 0.13; RR=0.46, 95% CI [0.17, 1.25]). The certainty of evidence was rated as "very low".

CONCLUSIONS

Direct and indirect resin composite restorations may show similar clinical longevity in posterior region, regardless of the observation period or substrate (wear-affected and non-affected dentition). The very low quality of evidence suggests that more long-term RCTs are needed to confirm our results.

Success and complication rates of non-precious alloy telescopic crowns in a general dental practice

OBJECTIVES

This retrospective, single-center, practice-based cohort study aimed to analyze factors associated with the success of removable partial dentures retained by telescopic crowns (TRPD).

MATERIALS AND METHODS

TRPD which were placed in a single practice of a practice-based research network were analyzed. Data from 139 patients (age (SD): 66 (11) years; 66 female) with 174 TRPD including 488 non-precious alloy telescopic crowns (TC) between 2004 and 2016 were included. TC without any technical complication were considered as successful, and as survived, if they were still in function at the last check-up. Multilevel Cox proportional hazard models were used to evaluate the association between clinical factors and time until failure.

RESULTS

Within a mean follow-up period (SD) of 4.2 (3.3) years (min-max: 1 day-12 years), 372 (76%) TC (AFR5years,TC-level: 5.0%) as well as 136 (87%) TRPD (AFR5years,TRPD-level: 5.1%) ("worst-case scenario") and 150 (86%) TRPD (AFR5years,TRPD-level: 3.4%) ("best-case scenario") were considered as successful. The main failure types were recementation (n = 39), endodontic treatment (n = 36), and extraction (n = 35). TC in male patients showed 1.6 times higher risk for failure than in female patients (95%CI: 1.1-2.4; p = 0.023). TC on premolars showed 2.2 times higher risk for failure than on incisors (95%CI: 1.1-5.0; p = 0.023) and TC in dentures with ≤ 3TC showed 2.1 times higher risk for failure than TC in dentures with > 3TC (1.3-3.4; p = 0.042). Furthermore, TC on the most distal tooth in an arch showed 2.4 times higher risk for failure than TC on a more mesial tooth (1.5-3.8; p < 0.001).

CONCLUSION

For removable partial dentures retained by telescopic crowns, high success rates could be found after up to 12 years. Patient-level and tooth-level factors were significantly associated with failure.

CLINICAL RELEVANCE

For removable partial dentures retained by telescopic crowns, high success rates could be found after up to 12 years. Patient-level and tooth-level factors were significantly associated with failure.

Retrospective clinical study on the performance and aesthetic outcome of pressed lithium disilicate restorations in posterior teeth up to 8.3 years

OBJECTIVES

Evaluation of cumulative survival and complication rate of monolithic lithium disilicate inlays and partial crowns performed by supervised undergraduate students up to 8.3 years of clinical service.

MATERIALS AND METHODS

In this retrospective clinical study 143 lithium disilicate posterior restorations (IPS e.max Press) were examined according to the FDI criteria. A standardised questionnaire was used to determine patient satisfaction. The aesthetic outcome was evaluated by dentists and dental technicians using intraoral photographs. Data were descriptively analysed. Cumulative survival and success rates were calculated using Kaplan-Meier estimation.

RESULTS

The cumulative survival rate of lithium disilicate restorations was 97.5% after a mean service time of 5.9 years and 95.0% after 8.3 years. The cumulative success rate decreased from 94.4% after 5.9 years to 30.7% after 8.3 years. Repairs were required for 7 restorations (4.9%), and 5 (3.5%) were classified as failures. The results of the questionnaire indicate a high level of patient satisfaction. The subjective aesthetics were assessed more critically by dental technicians compared to dentists.

CONCLUSION

Lithium disilicate posterior restorations survived successfully up to 8.3 years when carried out by undergraduate students.

CLINICAL RELEVANCE

Pressed lithium disilicate glass ceramic inlays and partial crowns are reliable treatment options in posterior teeth.

Fatigue and marginal adaptation of bulk fill restoratives: Effect of the layering technique and cavity dimension of extensively damaged teeth

OBJECTIVES

To evaluate the effect of layering technique and cavity dimension on the fatigue behavior and marginal adaptation of bulk fill (BF) restorations in extensively damaged teeth.

METHODS

Seventy-two premolars received class II cavities (MOD) followed by endodontic treatment. Half sample had 1/3 of their palatal cusp removed. Teeth were restored using three techniques: (I) incremental, with conventional resin composite (RC); (C) combined, using BF flow and RC, (B) bulk fill, with regular BF. Specimens were subjected to fatigue (80 N, 2 Hz, 37° C water) for 1 million cycles (n = 12). The test was interrupted every 250,000 cycles to evaluate tooth integrity, restoration fracture and adaptation using FDI criteria. Images of the proximal surfaces were obtained before and after the cycling to measure the gap. Restoration fatigue survival and success were analyzed using Weibull distribution and Maximum Likelihood Estimation. Gap thickness was analyzed with Kruskal-Wallis and Student-Newman-Keuls tests (α = 0.05).

RESULTS

For the survival analysis, Weibull modulus (β) and characteristic lifetime (η) were similar among groups. Yet, for the success analysis, in which only restorations that were free of technical complications were ranked as success, the bulk-fill technique resulted in higher β, while the combined technique produced restorations with higher η, for teeth that had their cusp removed. C-technique also resulted in smaller gaps than I and B.

SIGNIFICANCE

The effect of the layering technique on the success of restorations was dependent on the cavity extension. The combined technique favors the adaptation and the longevity of extensively damaged teeth.

Clinical longevity of intracoronal restorations made of gold, lithium disilicate, leucite, and indirect resin composite: a systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review and meta-analysis is to assess the comparative clinical success and survival of intracoronal indirect restorations using gold, lithium disilicate, leucite, and indirect composite materials.

MATERIAL AND METHODS

This systematic review and meta-analysis were conducted following the Cochrane Handbook for Systematic Reviews of Interventions and PRISMA guidelines. The protocol for this study was registered in PROSPERO (registration number: CRD42021233185). A comprehensive literature search was conducted across various databases and sources, including PubMed/Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials.gov, and gray literature. A total of 7826 articles were screened on title and abstract. Articles were not excluded based on the vitality of teeth, the language of the study, or the observation period. The risk difference was utilized for the analyses, and a random-effects model was applied. All analyses were conducted with a 95% confidence interval (95% CI). The calculated risk differences were derived from the combined data on restoration survival and failures obtained from each individual article. The presence of heterogeneity was assessed using the I2 statistic, and if present, the heterogeneity of the data in the articles was evaluated using the non-parametric chi-squared statistic (p < 0.05).

RESULTS

A total of 12 eligible studies were selected, which included 946 restorations evaluated over a minimum observation period of 1 year and a maximum observation period of 7 years. Results of the meta-analysis indicated that intracoronal indirect resin composite restorations have an 18% higher rate of failure when compared to intracoronal gold restorations over 5-7 years of clinical service (risk difference =  - 0.18 [95% CI: - 0.27, - 0.09]; p = .0002; I2 = 0%). The meta-analysis examining the disparity in survival rates between intracoronal gold and leucite restorations could not be carried out due to methodological differences in the studies.

CONCLUSIONS

According to the currently available evidence, medium-quality data indicates that lithium disilicate and indirect composite materials demonstrate comparable survival rates in short-term follow-up. Furthermore, intracoronal gold restorations showed significantly higher survival rates, making them a preferred option over intracoronal indirect resin-composite restorations. Besides that, the analysis revealed no statistically significant difference in survival rates between leucite and indirect composite restorations. The short observation period, limited number of eligible articles, and low sample size of the included studies were significant limitations.

CLINICAL SIGNIFICANCE

Bearing in mind the limitations of the reviewed literature, this systematic review and meta-analysis help clinicians make evidence-based decisions on how to restore biomechanically compromised posterior teeth.

Clinical survival and performance of premolars restored with direct or indirect cusp-replacing resin composite restorations with a mean follow-up of 14 years

OBJECTIVES

The objective is to evaluate the long-term clinical survival and performance of direct and indirect resin composite restorations replacing cusps in vital upper premolars.

METHODS

Between 2001 and 2007, 176 upper premolars in 157 patients were restored with 92 direct and 84 indirect resin composite restorations as part of an RCT. Inclusion criteria were fracture of the buccal or palatal cusp of vital upper premolars along with a class II cavity or restoration in the same tooth.

RESULTS

Forty patients having 23 direct and 22 indirect composite restorations respectively, were lost to follow-up (25.6%). The cumulative Kaplan-Meier survival rates were 63.6% (mean observation time: 15.3 years, SE 5.6%) with an AFR of 2.4% for direct restorations and 54.5% (mean observation time: 13.9 years, SE: 6.4%) with an AFR of 3.3% for indirect restorations. The Cox regression analysis revealed a statistically significant influence of the patient's age at placement on the survival of the restoration (HR 1.036, p = 0.024), the variables gender, type of upper premolar, type of restoration, and which cusp involved in the restoration had no statistically significant influence. Direct composite restorations failed predominantly due to tooth fracture, indirect restorations primarily by adhesive failure (p < 0.05).

SIGNIFICANCE

There was no statistically significant difference in survival rates between direct and indirect composite cusp-replacing restorations. Both direct and indirect resin composite cusp-replacing restorations are suitable options to restore compromised premolars. The longer treatment time and higher costs for the indirect restoration argue in favor of the direct technique.

Number of consecutive procedures after endodontic treatment to extraction: A 28-year retrospective study

STATEMENT OF PROBLEM

After endodontic treatment, teeth may require additional treatment. Data regarding the number of treatments up to extraction after endodontic treatment are lacking.

PURPOSE

The purpose of this retrospective study was to evaluate the number of consecutive restorative procedures performed on a specific tooth starting from endodontic treatment up to extraction. A comparison was made between crowned and uncrowned teeth.

MATERIAL AND METHODS

A retrospective study was conducted using 28 years of data from a private clinic. The total number of patients was 18 082 and included 88 388 treated teeth. The data were collected for permanent teeth that received at least 2 consecutive retreatments. The data included tooth number, procedure type, date of procedure, total number of procedures conducted during the study period, extraction date, time from endodontic treatment to extraction, and whether the tooth had been crowned or not. Endodontically treated teeth were divided into 2 groups: extracted and nonextracted. In each group, a comparison was made between crowned and uncrowned teeth and between anterior and posterior teeth by using the Student t test (α=.05).

RESULTS

In the non extracted group, teeth that were crowned required significantly (P<.05) fewer restorative treatments (mean ±standard deviation 2.9 ±2.1) than uncrowned teeth (5.01 ±2.98). For extracted teeth, the mean time from endodontic treatment until extraction was 10.39 years. Crowned teeth were extracted after a mean of 11.06 years and 3.98 treatments, while uncrowned teeth were extracted after a mean of 9.96 years and 7.22 treatments (P<.05).

CONCLUSIONS

Endodontically treated teeth that were crowned required significantly fewer subsequent restorative procedures than uncrowned teeth and exhibited higher survival rates up to extraction.

A 23-Year Observational Follow-Up Clinical Evaluation of Direct Posterior Composite Restorations

The purpose of this observational follow-up clinical study was to observe the quality of posterior composite restorations more than 23 years after application. A total of 22 patients, 13 male and 9 female (mean age 66.1 years, range 50–84), with a total of 42 restorations attended the first and second follow-up examinations. The restorations were examined by one operator using modified FDI criteria. Statistical analysis was performed with the Wilcoxon Mann–Whitney U test and Wilcoxon exact matched-pairs test with a significance level of p = 0.05. Bonferroni–Holm with an adjusted significance level of alpha = 0.05 was applied. With the exception of approximal anatomical form, significantly worse scores were seen for six out of seven criteria at the second follow-up evaluation. There was no significant difference in the first and second follow-up evaluations in the grades of the restorations with regard to having been placed in the maxilla or mandible, as well as for one-surface or multiple-surface restorations. The approximal anatomical form showed significantly worse grades at the second follow-up when having been placed in molars. In conclusion, the study results show that significant differences regarding FDI criteria in posterior composite restorations occur after more than 23 years of service. Further studies with extended follow-up time and at regular and short time intervals are recommended.

Clinical longevity of extensive direct resin composite restorations after amalgam replacement with a mean follow-up of 15 years

OBJECTIVES

The aim of this retrospective clinical study was to determine the survival of extensive direct resin composite restorations after amalgam replacement on vital molars and premolars after a mean observation period of 15 years.

METHODS

Between January 2007 and September 2013, a total of 117 extensive cusp replacing direct resin composite restorations were placed in 88 patients in a general dental practice. These were indicated for replacement of existing amalgam restorations. Tooth vitality, the absence of at least one cusp in premolars, and at least two cusps in molars were considered for inclusion. The long-term follow-up of the restorations, re-evaluated after up to 17 years using the original evaluation criteria is reported.

RESULTS

81 of 88 patients (92.1%) and 106 of 117 restorations (90.6%) were available for follow-up. The cumulative success rate was 62.0% (95% CI: 47.3-76.2, AFR 2.79%) after a mean observation time of 163.4 months, the cumulative survival rate was 74.7% (95% CI: 59.8-89.6%, AFR: 1.70%) after a mean observation time of 179.1 months. The number of cusps replaced in premolars had a statistically significant influence on the success and survival rate of the restorations (HR of respectively, 2.974 and 3.175, p = <0.0005). Premolars with two cusps replaced had 297% more chance of failure than premolars with one cusp replaced.

CONCLUSIONS

Extensive direct resin composite restorations placed after amalgam replacement showed good survival after a mean observation period of 15 years. The number of cusps involved had a statistically significant influence on the longevity of the restorations in premolars.

CLINICAL SIGNIFICANCE

With good survival and low annual failure rates, direct resin composite restorations are a suitable treatment for repairing extensive defects in posterior teeth involving multiple cusps and surfaces, provided that they are placed by a dentist who has long experience and is skilled in the placement of direct composite materials.

Longevity of composite restorations is definitely not only about materials

OBJECTIVES

This review study provides an overview of factors that influence the longevity of all types of direct resin composite restorations.

METHODS

A systematic search was performed in PubMed, Scopus, and Web of Science databases for articles reporting data from primary longitudinal clinical studies on composite longevity published 2011-2021. Prospective or retrospective studies with restorations in permanent dentition, with follow-up periods of at least 5 years were included.

RESULTS

In total, 33 articles were included with different study designs, practice settings, datasets, countries of origin, and sample sizes. Annual failure rates of restorations ranged from 0.08% to 6.3%. Survival rates varied between 23% and 97.7%, success rates varied between 43.4% and 98.7%. Secondary caries, fractures, and esthetic compromise were main reasons for failures. Risk factors for reduced restoration durability included patient-level factors (e.g., caries risk, parafunctional habits, number of check-ups per year, socioeconomic status), dentist factors (different operators, operator's experience), and tooth/restoration factors (endodontic treatment, type of tooth, number of restored surfaces). Patient gender and the composite used generally did not influence durability.

SIGNIFICANCE

A number of risk factors are involved in the longevity of composite restorations. Differences between composites play a minor role in durability, assuming that materials and techniques are properly applied by dentists. Patient factors play a major role in longevity. The decision-making process implemented by dentists relative to the diagnosis of aging or failed restorations may also affect the longevity of restorations. Clinicians should treat patients comprehensively and promote a healthy lifestyle to ensure longevity.

Resin Composites in Posterior Teeth: Clinical Performance and Direct Restorative Techniques

Resin composites are the most versatile restorative materials used in dentistry and the first choice for restoring posterior teeth. This article reviews aspects that influence the clinical performance of composite restorations and addresses clinically relevant issues regarding different direct techniques for restoring posterior teeth that could be performed in varied clinical situations. The article discusses the results of long-term clinical trials with resin composites and the materials available in the market for posterior restorations. The importance of photoactivation is presented, including aspects concerning the improvement of the efficiency of light-curing procedures. With regard to the restorative techniques, the article addresses key elements and occlusion levels for restoring Class I and Class II cavities, in addition to restorative strategies using different shades/opacities of resin composites in incremental techniques, restorations using bulk-fill composites, and shade-matching composites.

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.

Influence of Practitioner-Related Placement Variables on the Compressive Properties of Bulk-Fill Composite Resins-An In Vitro Clinical Simulation Study

Aims: To determine if restoration location and/or execution behavior force parameters have an influence on the mechanical properties of bulk-fill composite dental restorations. Methods: Pressure transducers were placed within each quadrant of dental mannequin jaws. Cylindrical molds were placed above the transducers and filled with two bulk-fill composite materials, Filtek and Tetric, by four experienced dentists. Each dentist prepared five specimens per quadrant and material. The total placement time, mean force, number of peak forces (above 25 N), and mean peak(s) force during placement were measured. Then, the stiffness and maximal compressive strength of the specimens were determined while loading the specimens up to failure using a universal loading machine. Results: Placement time was affected by jaw (p < 0.004) and side (p < 0.029), with the shortest time demonstrated for the left side of the mandible. Force exerted during restoration placement was not normally distributed without differences in location (jaw) or material. A higher application force was found on the right side (p < 0.01). The number of peak forces was affected by side (p < 0.03), with less peaks on the left side. No significant differences were found in compressive strength when correlated to restoration location, participant, or material (p = 0.431). The stiffness values of Filtek (3729 ± 228 N/mm) were found to be 15% higher than Tetric (3248 ± 227 N/mm) (p < 0.005). No correlations were found between the compressive strength or stiffness and the amount of force applied during placement. Conclusions: The individual restoration material placement parameters did influence practitioner performance; however, these differences did not affect the mechanical properties of the final restoration.

Longevity of immediate rehabilitation with direct metal-wire reinforced composite fixed partial dentures

OBJECTIVES

This study aimed to analyze the longevity of direct metal-wire reinforced composite fixed partial dentures (MRC-FPD) and factors influencing their survival and success.

METHODS

Within one private practice 513 MRC-FPD were directly applied. The preparation of a proximal cavity in abutment teeth was not limited. MRC-FPD were reinforced by one to three metal-wires. At the last follow-up MRC-FPD were considered successful, if they were still in function without any need of therapy. MRC-FPD were considered as survived, if they were repaired or replaced. Multi-level Cox proportional hazard models were used to evaluate the association between clinical factors and time.

RESULTS

Mean follow-up period (range) was 59(2-249) months. Seventy-three bridges did not survive (cumulative survival rate(CSR):86%) and further 129 bridges had received a restorative follow-up treatment (CSR:61%). AFR was 2.2% for survival and 8.6% for success. In multivariate analysis MRC-FPD with> 1 wire showed a up to 2.3x higher failure rate than MRC-FPD with one wire(p ≤ 0.023). Dentist's experience in designing MRC-FDP (p ≤ 0.017), patient's caries risk (p ≤ 0.040) and bruxism (p = 0.033) significantly influenced the failure rate: the more experience, the lower caries risk and bruxism, the lower the failure rate.

SIGNIFICANCE

For directly prepared metal-wire reinforced composite bridges high survival and moderate success rates were observed. MRC-FPD might, thus, be an immediate, short- and medium-term solution for replacing missing teeth. However, several factors on the levels of practice (dentist's experience in designing MRC-FDP), patient (bruxism, caries risk) and restoration (number of wires) were identified as significant predictors for the failure rate. The study was registered in the German Clinical Trials Register (DRKS-ID: DRKS00021576).

Microhardness homogeneity of RBCs light-cured with a multiple-peak LED and surface characterization after wear

This in vitro study evaluated the effect of the beam homogeneity of a multiple-peak light-curing unit on the surface microhardness and the effect of toothbrushing wear on the microhardness, surface roughness, roughness profile, volume loss, and gloss retention of incremental and bulk-fill resin-based composites (RBCs). A LED light-curing unit (VALO) with four LEDs at the tip end (405, 445, 465A, and 465B nm emission peak) was used according to each manufacturer-recommended time to obtain disks (n=10) of six RBCs: Estelite Sigma Quick, Charisma Classic, Tetric EvoCeram Bulk Fill, Filtek Z250, Filtek Supreme Ultra, and Filtek Bulk Fill. Microhardness values were obtained according to each LED positioning of the light-curing unit on the top surface of the RBCs and were analyzed before and after toothbrushing regarding microhardness, surface roughness, roughness profile, volume loss, and gloss retention. Microhardness was considered homogeneous on the top surface regardless of the type of RBC or wavelength tested (p>0.05). Overall, toothbrushing did not reduce the microhardness of the RBCs but influenced the gloss values for most RBCs (p<0.001). Charisma Classic presented the greatest surface roughness and roughness profile after toothbrushing (p<0.05). Volume loss did not differ among RBCs (p>0.05). In conclusion, different wavelengths of the LED did not affect the top surface microhardness, regardless of the RBCs tested; and bulk-fill composites presented similar surface changes (microhardness, surface roughness, roughness profile, volume loss, and gloss retention) when compared to conventional composites after toothbrushing.

The survival time of restorations is shortened in patients with dry mouth

OBJECTIVES

The aim of this retrospective data collection study was to determine the effect size of dry mouth on the survival of restorations and teeth.

METHODS

The data were collected from the electronic patient files of City of Oulu Public Dental Services (Finland). Study population consisted of 71 dry mouth patients and 142 control patients. The survival of 3208 restorations were analyzed using Kaplan-Meier survival curves and multivariate Cox regression analysis with shared frailty for patients. Separate analyses were performed for the survival of the teeth.

RESULTS

The hazard ratio of restorations in dry mouth patients was 2.08 (95% CI: 1.65-2.63) compared to the control patients. For the dry mouth patients, the fixed prosthetic crowns outlasted composite fillings of all sizes, but the difference increased concomitantly with the filling size. The dry mouth patients had hazard ratio of 1.98 (95% CI: 1.02-3.82) for tooth extractions compared to the control patients. The teeth with fixed prosthetic crowns outlasted the teeth with direct restorative materials.

CONCLUSIONS

The survival time of restorations and teeth are severely shortened in patients with dry mouth. Especially the survival time of the large composites is short in dry mouth patients whereas fixed prosthetic crowns have acceptable survival time also in dry mouth patients.

CLINICAL SIGNIFICANCE

When informing a dry mouth patient on the expected survival of a restoration or tooth, one should take into account that dry mouth patients´ restorations and teeth have severely shortened survival time.

Needs for re-intervention on restored teeth in adults: a practice-based study

OBJECTIVES

Evaluate the need for re-intervention on dental coronal restorations in adults seen in a network of general dental practitioners (ReCOL).  MATERIALS AND METHODS: This observational, cross-sectional, multicenter study involved 40 practitioners and 400 patients. Coronal restoration failures (needing re-intervention for unsatisfactory outcomes) were assessed with a simplified rating scale of seven criteria from the FDI World Dental Federation. The oral health status, the risk factors, and Oral Health Impact Profile-14 were also examined. Previous restoration characteristics (extent, technique, material) were analyzed according to the need for re-intervention (yes/no), the age group, and the risk profile. Qualitative variables were compared between "re-intervention" and "no re-intervention" group using Fisher exact test.

RESULTS

The need for re-intervention was estimated at 74% (95% CI: 70; 79); it increased with age (49 to 90%), unfavorable risk profile (82 vs. 62%), and extent of the filling (32, 39, 44, and 44% on 1, 2, 3 surfaces, and crowns, respectively). More posterior than anterior teeth were restored (median per patient: 6 vs. 1) or needed re-intervention (median per patient: 1 vs. 0).

CONCLUSIONS

The needs for re-intervention in adults are still high within a context of ever-changing materials and techniques, simplified and rationalized decision-makings, and demands for patient involvement.

CLINICAL RELEVANCE

Meeting these needs requires the following: (i) consensus definitions and assessment methods for "failure" and (ii) reliable feedbacks on materials, procedures, and satisfaction. Building large and detailed databases fed by networks of motivated practitioners will help analyzing complex success/failure data by artificial intelligence and guiding treatment and research.

A retrospective clinical study on the survival of posterior composite restorations in a primary care dental outreach setting over 11years

OBJECTIVES

To investigate the survival in terms of time to re-intervention of composite restorations in posterior teeth among patients attending for treatment at a primary care dental outreach setting over an 11-year period and to determine whether dental, patient or operator factors influenced this.

METHODS

Electronic primary dental care data were collected on individual patients, including information on their dental treatment and socio-demographics as well as service provision, key performance indicators and student activity.

RESULTS

A total of 1086 patients had at least one posterior composite placed between 2007 and 2018. This amounted to 3194 restorations placed of which 308 had a re-intervention within the 11-year period. For all restorations, the annual failure rate at 1 year was 5.73 %, at 5 years was 16.78 % and at 10 years was 18.74 %. A logistic regression showed that when compared to the least deprived 5^th quintile, the most deprived 1^st and 2^nd quintiles were significantly less likely to have a re-intervention, being 49.2 % (p = 0.022) and 53.2 % (p = 0.031) less likely, respectively.

CONCLUSIONS

The survival rates of posterior composite restorations placed at a single outreach centre providing undergraduate dental training in the South of England, mirrors other studies. The new findings presented suggest similar re-intervention rates between dental students and dental hygiene-therapy students. This study's findings around patient deprivation and rate and time of re-intervention raises important questions related to the need for targeted dental and after care for certain groups in the population.

CLINICAL SIGNIFICANCE

Understanding the factors associated with re-intervention of restorations provided to patients has an impact on patients and dental practices. Also, as we consider widening use of skill mix in dentistry to increase access to care, parity in provision of treatments within the dental team increases opportunities for delegation of tasks.

Age-related variation in volume and content of restorative private dental care for adults in Finland in 2012-2017: A nationwide register-based observation

OBJECTIVES

This study assessed age-related variation in the volume and content of restorative dental care performed by private dentists for adults in Finland in 2012-2017.

METHODS

This retrospective register-based observational study utilized the Social Insurance database of private dental services in 2012 and 2017, including all patients. The data were aggregated into 5-year age groups for 20-89-year-olds; those aged 90+ formed one group. A patient was one who had received at least one treatment, and a restoration patient one who received at least one restoration (direct/indirect), excluding prosthetic crowns. Attendance rate was the proportion of the population treated. Volume of restorative treatment was the proportion of restoration patients among all patients using private dental services. Content of restorative treatment was described as the number of teeth receiving restoration and the size of restoration (number of surfaces restored). Correlation coefficient demonstrated associations between age groups and numbers of restorations.

RESULTS

Rate of restoration patients was 64.8 % in 2012 and 61.1 % in 2017, the rate for individuals aged under 80 years in each calendar year being smaller than in previous years. Mean number of restorations received per patient was 1.59 in 2012 and 1.42 in 2017, increasing with age (r = 0.85 in 2012; r = 0.95 in 2017). Small restorations dominated; one to two surfaces were covered in 72.3 % and 75.5 % of restorations in 2012 and 2017, respectively.

CONCLUSIONS

Volume and content of restorative dental care for adults vary by age and have decreased slightly over time.

CLINICAL SIGNIFICANCE

Restorative treatments are a prominent part of dental care for adults. This paper sheds light on the entity of restorative dental care for adults visiting private dentists. Variation in restoration volume and content is shown according to patient's age group, and changes are assessed across six years.

Use of digital periodontal data to compare periodontal treatment outcomes in a practice-based research network (PBRN): a proof of concept

Background

Scientific studies in dentistry are mainly conducted at universities. However, most patients are treated in dental practices, which differ in many ways from treatment at the university. Through the establishment of practice-based research networks, however, it is also possible to examine studies in a real-world setting in dental practices. For this reason the aim of this non-interventional, observational study was to develop and evaluate a digital procedure to access, extract and analyse recorded clinical data in practices to assess periodontal treatment outcomes.

Methods

Participating periodontists were former or active postgraduate students of a master’s course in periodontics in Freiburg who routinely used a digital periodontal diagnostic program. All available stored periodontal patient charts were extracted, anonymized and digitally sent to the study centre.

Results

In this study, data were collected from 6301 patients from 9 different practices. Information such as probing depth (PD), bleeding on probing (BOP), mobility, furcation and gingival attachment for 153,163 teeth at first visit were successfully transferred to the study centre. During the average observational period of 9.77 years, only 2.8% of all teeth were lost. The number of visits was significantly negatively correlated with BOP (p < 0.0001), and the number of BOP-positive sites was significantly correlated with deeper PDs (p < 0.001).

Conclusion

The presented procedure was able to gather a large amount of practice-based periodontal data, and thus this study may support practice-based research networks. The data indicate that systematic and supportive periodontal therapy is successful on a practice-based level.

Trial registration The study was internationally registered on 4 January 2017 in the German Clinical Trials Register (DRKS 00011448). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011448

10.9-year survival of pressed acid etched monolithic e.max lithium disilicate glass-ceramic partial coverage restorations: Performance and outcomes as a function of tooth position, age, sex, and the type of partial coverage restoration (inlay or onlay)

STATEMENT OF PROBLEM

Long-term clinical data on the survival of pressed lithium disilicate glass-ceramic when used with partial coverage restorations and the effect that different technical and clinical variables have on survival are sparse.

PURPOSE

The purpose of this clinical study was to determine the 10.9-year survival of pressed lithium disilicate glass-ceramic partial coverage restorations and associated clinical parameters on outcomes.

MATERIAL AND METHODS

Individuals requiring single unit defect-specific partial coverage restorations in any area of the mouth were recruited in a clinical private practice. Participants were offered the options of partial coverage cast gold or glass-ceramic (lithium disilicate) restorations. Only participants that chose glass-ceramic partial coverage restorations were included in the study. The overall survival of the glass-ceramic restorations was assessed by the clinical factors (participant's age, sex, dental arch, tooth position in dental arch, type of partial coverage restoration, and ceramic thickness) determined at recall. The effect of this clinical parameters was evaluated by using Kaplan-Meier survival curves accounting for attrition bias and other reasons for failure. The statistical significance of differences between parameters was determined by using the log rank test (α=.05).

RESULTS

A total of 304 participants requiring 556 lithium disilicate restorations were evaluated. The mean age for the participant at the time of restoration placement was 62 with a range of 20 to 99 years, 120 were men and 184 were women. A total of 6 failures (bulk fracture or large chip) requiring replacement were recorded with the average time to failure of 2.4 (0.8-9.2) years. The total time at risk computed for these units was 1978.9 years providing an estimated failure risk of 0.3% per year. The 10-year estimated cumulative survival was 95.6%. The estimated cumulative survival of inlays (n=246) and onlays (n=305) were 93.9% and 98.3%, at 9.9 and 9.8 years, respectively (P<.05). Of the 6, there were 3 failures recorded for the partial coverage inlay restorations. The total time at risk for these inlays was 786.79 years providing an estimated risk of 0.38% per year. The other 3 failures recorded occurred for the partial coverage onlay restorations. The total time at risk for the onlays was 1032.17 years providing an estimated risk of 0.29% per year. The failures occurred in the molar region only. There were no failures recorded for the anterior partial coverage inlays (n=5). The total time at risk computed for the anterior units was 21.55 years providing an estimated risk of 0% per year. There was no statistically significant difference in the survival of partial coverage restorations among men and women, different age groups, or position in the dental arch. The thickness of the restoration had no influence on the survival of glass-ceramic partial coverage restorations.

CONCLUSIONS

Pressed lithium disilicate defect-specific partial coverage restorations reported high survival rate over the 10.9-year period with an overall failure rate of 0.3% per year and limited to the molar teeth. Risk of failure at any age was minimal for both men and women.

Current perspectives on dental adhesion: (1) Dentin adhesion - not there yet

The essential goal of any adhesive restoration is to achieve a tight and long-lasting adaptation of the restorative material to enamel and dentin. The key challenge for new dental adhesives is to be simultaneously effective on two dental substrates of conflicting nature. Some barriers must be overcome to accomplish this objective. While bonding to enamel by micromechanical interlocking of resin tags within the array of microporosities in acid-etched enamel can be reliably achieved and can effectively seal the restoration margins against leakage, bonding effectively and durably to organic and humid dentin is the most puzzling task in adhesive dentistry.

Much of the research and development of dental adhesives has focused on making the clinical procedure more user-friendly by reducing the number of bottles and/or steps. Although clinicians certainly prefer less complicated and more versatile adhesive materials, there is a trade-off between simplification of dental adhesives and clinical outcomes. Likewise, new materials are launched with claims of being novel and having special properties without much supporting evidence.

This review article discusses dental adhesion acknowledging pioneer work in the field, highlights the substrate as a major challenge to obtain durable adhesive restorations, as well as analyzes the three adhesion strategies and their shortcomings. It also reviews the potential of chemical/ionic dental adhesion, discusses the issue of extensively published laboratory research that does not translate to clinical relevance, and leaves a few thoughts in regard to recent research that may have implications for future adhesive materials.

Treatment options for large posterior restorations: a systematic review and network meta-analysis

BACKGROUND

The best treatment option for large caries in permanent posterior teeth is still a matter of uncertainty in dental literature. The authors conducted a network meta-analysis to address the challenges related to rehabilitation of these teeth.

TYPES OF STUDIES REVIEWED

The authors selected prospective and retrospective studies that compared at least 2 different treatment alternatives for permanent teeth with a minimum of 5 years of follow-up. The authors searched databases from MEDLINE, Scopus, Cochrane Library, and Web of Science in October 2019 without language or year of publication restrictions.

RESULTS

From 11,263 studies identified, 43 studies fulfilled the eligibility criteria and were included in the final review. Only 13 studies were randomized controlled trials and were classified as low risk of bias. Gold (annual failure rate of 0.29%) and metal ceramic (annual failure rate of 0.52%) crowns performed better for indirect restorations and direct resin composite performed better for direct restorations (annual failure rate of 2.19%). The most substantial comparisons were between feldspathic and glass ceramics, followed by direct resin composite and amalgam; there were no statistically significant differences between these interventions. Results of the pairwise meta-analysis showed mainly glass ionomer as significantly more prone to failure than amalgam and direct composite resin.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Reference standard direct and indirect materials except for glass ionomer can be used for restorations of large posterior caries.

Type and time of first re-intervention of posterior restorations - 13-year scenario at the public dental service

Objectives: We investigated the first re-interventions of two- and three-surface direct restorations on posterior teeth, specifically noting the type and time of the first re-intervention.Materials and methods: In 2002, altogether 5542 posterior two- and three-surface composite and amalgam restorations were done for 3051 patients aged 25-30 years at Helsinki City Public Dental Service (PDS). Based on electronic patient records, we analysed all restorations (n = 2445) having re-intervention during a 13-year follow-up. We recorded the type of tooth, restoration size, and type of first re-intervention. The time to re-intervention was the interval between the date of the placement of restoration at the year 2002 and its first re-intervention.Results: Restorative treatment was the most common (77.9%) first re-intervention, followed by endodontics (11.5%), extractions (5.2%), and other (5.4%). Males, more frequently than females, had extraction or endodontics as first re-intervention. The average time to re-intervention was 5.7 years (SD 3.8; median 5.2). Both median and mean times were shortest for cases involving endodontics or extractions.Conclusions: For the majority of two- and three-surface posterior restorations, the first re-intervention is restorative (replacement or repair of restoration). The shortest time to re-intervention is for restorations that have endodontics or extraction as the first re-intervention.

Risk Factors for Failure of Direct Restorations in General Dental Practices

The aim of this retrospective noninterventional multicenter practice-based study was to analyze factors influencing the survival of direct restorations. Records from patients who visited 5 private practices regularly were searched for the presence of direct restorations. Data were recorded from 7,858 patients with 27,407 direct restorations being detected at least 6 mo before the last recall visit. Multilevel Cox proportional hazard models were used to evaluate the association between clinical factors and time until failure. Within 228 mo, 5,493 failures could be observed. Median survival time was 207 mo. The annual failure rates were 3.8%, 4.0%, 4.6%, 4.9%, and 3.9% for class I, II, III, IV, and V restorations, respectively. Class II and IV restorations showed a 1.1-times (95% CI, 1.0 to 1.2) and 1.2-times (95% CI, 1.1 to 1.2) higher failure rate than class I restorations ( P ≤ 0.029). Patients aged <20 y and >60 y showed up to a 1.4-times higher failure rate than patients aged 20 to 60 y ( P ≤ 0.015). Restorations that underwent check-up twice a year or more showed a significantly higher failure rate than those that did so less than twice a year ( P < 0.001). Furthermore, the dentists significantly influenced time until failure ( P < 0.001). Regarding the restorative material, composites showed up to a 2.1-times longer time until failure than GIC ( P ≤ 0.020). Moderate failure rates were observed for direct restorations in the private practice setting after up to 18.5 y. Within the limitations of the present study, several factors on the levels of practice (i.e., dentist), patient (i.e., age), and tooth (i.e., restorative material, restored surfaces according to the classification of Black) were significant predictors for the failure rate. Therefore, treatment decision should take into account most relevant factors (German Clinical Trials Register DRKS00015228).

Leveraging Electronic Dental Record Data for Clinical Research in the National Dental PBRN Practices

OBJECTIVES

The aim of this study is to determine the feasibility of conducting clinical research using electronic dental record (EDR) data from U.S. solo and small-group general dental practices in the National Dental Practice-Based Research Network (network) and evaluate the data completeness and correctness before performing survival analyses of root canal treatment (RCT) and posterior composite restorations (PCR).

METHODS

Ninety-nine network general dentistry practices that used Dentrix or EagleSoft EDR shared de-identified data of patients who received PCR and/or RCT on permanent teeth through October 31, 2015. We evaluated the data completeness and correctness, summarized practice, and patient characteristics and summarized the two treatments by tooth type and arch location.

RESULTS

Eighty-two percent of practitioners were male, with a mean age of 49 and 22.4 years of clinical experience. The final dataset comprised 217,887 patients and 11,289,594 observations, with the observation period ranging from 0 to 37 years. Most patients (73%) were 18 to 64 years old; 56% were female. The data were nearly 100% complete. Eight percent of observations had incorrect data, such as incorrect tooth number or surface, primary teeth, supernumerary teeth, and tooth ranges, indicating multitooth procedures instead of PCR or RCT. Seventy-three percent of patients had dental insurance information; 27% lacked any insurance information. While gender was documented for all patients, race/ethnicity was missing in the dataset.

CONCLUSION

This study established the feasibility of using EDR data integrated from multiple distinct solo and small-group network practices for longitudinal studies to assess treatment outcomes. The results laid the groundwork for a learning health system that enables practitioners to learn about their patients' outcomes by using data from their own practice.

Secondary caries: what is it, and how it can be controlled, detected, and managed?

OBJECTIVES

To assess how to control, detect, and treat secondary caries. This review serves to inform a joint ORCA/EFCD consensus process.

METHODS

Systematic and non-systematic reviews were performed or consulted and narratively synthesized.

RESULTS

Secondary (or recurrent) caries is defined as a lesion associated with restorations or sealants. While the restorative material itself has some influence on secondary caries, further factors like the presence and size of restoration gaps, patients' caries risk, and the placing dentist's experience seem more relevant. Current detection methods for secondary caries are only sparsely validated and likely prone for the risk of over-detection. In many patients, it might be prudent to prioritize specific detection methods to avoid invasive overtreatment. Detected secondary caries can be managed either by repair of the defective part of the restoration or its complete replacement.

CONCLUSIONS

There is sparse data towards the nature of secondary caries and how to control, detect, and treat it.

CLINICAL SIGNIFICANCE

Despite often claimed to be a major complication of restorations, there is surprisingly little data on secondary caries. Longer-term studies may be needed to identify differences in secondary caries risk between materials and to identify characteristic features of progressive lesions (i.e., those in need of treatment).

The differences between three performance measures on dental restorations, clinical success, survival and failure: A matter of perspective

OBJECTIVES

The aim of this retrospective methodology study was to investigate the influence of using different definitions for restoration failure and inclusion criteria on restoration longevity expressed in AFR.

METHODS

EPF from fifteen general dental practices were used for collecting the data for this study. From the EPF, 321,749 composite restorations placed in 52,245 patients by forty-seven GDPs between January 2000 and December 2011 were included. Kaplan-Meier statistics were applied and mean AFRs over 2, 5 and 10 years were calculated. The effect on the AFR of using different levels of failure: based on Claims data (CD), Success (SUC), Survival (SUR) and different inclusion criteria of tooth/restoration variables were reported.

RESULTS

Highest AFRs were found for level CD, in which every intervention was considered as failure, and the lowest AFRs for level SUR in which repairs and an endodontic treatments were not considered as a failure. AFRs increased when the observation period prolonged especially for SUR, followed by SUC and CD. An overview of long-term survival studies showed a wide variation in study design, performed clinical examination (USPHS criteria or GDP), number of restorations included, description of restoration failure and found AFRs for CD, SUC and SUR.

SIGNIFICANCE

Using failure criteria, Success and Survival, in future clinical studies would enable a better comparison of studies as well as demonstrate the impact of more conservative restorative intervention protocols on patient care.

Biomineralization of dentin

A single biomineralization of demineralized dentin is significant to restore the demineralized dentin due to dental caries or erosion. In recent years, meaningful progress has been made regarding the mechanisms involved in the biomineralization of dentin collagen. Concepts changing from the classical ion-based crystallization to non-classical particle-based crystallization, inspired a different strategy to infiltrate the demineralized dentin collagen. The remarkable discovery was the report of liquid-like amorphous calcium phosphate as nanoprecursor particles to carbonated hydroxyapatite. The non-collagenous proteins and their analogues are widely investigated, for their key role in controlling mineralization during the process of crystal nucleation and growth. The in-depth studies of the gap zone provided significant improvements in our understanding of the structure of collagen and of the intrafibrillar remineralization of collagen fibrils. The collagen is not a passive substrate as previously supposed, and the active role of guiding nanoprecursor infiltration and mediating its nucleation has been demonstrated. Furthermore, recovery of mechanical properties has been evaluated to determine the effectiveness of dentin remineralization. Finally, the problems regarding the origin formation of the calcium phosphate that is deposited in the collagen, and the exact interactions between the non-collagenous proteins, amorphous calcium phosphate and collagen are still unclear. We reviewed the importance of these findings in enriching our understanding of dentin biomineralization, while addressing certain limitations that are inherent to in vitro studies.

Dental practice in the UK in 2015/2016. Part 4: changes since 2002?

Objectives To determine, by means of anonymous self-report questionnaires, the changes in demographic profile, practising details and utilisation of clinical techniques/materials of general dental practitioners (GDPs) in the UK between 2002 and 2015. Method A wide-ranging, validated questionnaire, designed to elicit information on the practising arrangements and techniques and materials used, was distributed to UK-based GDPs in 2002, 2008 and 2015 with a request that they complete the questionnaire and return it by post in the reply-paid envelope to the corresponding author. Results Questionnaires were distributed by post to 1,000 UK-based GDPs in 2004 and 2008, with an additional 500 questionnaires being distributed at postgraduate meetings in 2015. Response rates of 70%, 66% and 78% were achieved, respectively. Of the respondents, 73% were male in 2002, while 67% and 60% were male in 2008 and 2015, respectively. In 2002, 65% were practice principals, falling to 51% in 2015. Regarding how patients paid for their dental care, 86% of respondents in 2002 treated patients within the NHS arrangements, compared with 57% and 50% in 2008 and 2015, respectively. The data collected in 2015 indicated that 55% of respondents had an intra-oral camera; while, with regard to recently introduced concepts and techniques, 80% used nickel-titanium files, 47% used zirconia-based bridgework, 25% used tricalcium silicate, and 17% used CAD/CAM restoration. Of great interest, perhaps, is the response to digital radiography/imaging, with the results indicating that, by 2015, 74% of respondents used this form of radiography. Conclusion Results from the three surveys indicated that NHS service provision has dropped to 50%. Regarding the staffing of dental practices, just over half the respondents were practice principals. The results also indicated that UK dentists continue to be innovative and forward-looking in the techniques that they employ.

Risk Factors for Dental Restoration Survival: A Practice-Based Study

To improve patient dental care, it is necessary to identify possible risk factors for the failing of restorations. This practice-based cohort study investigated the performance and influence of possible risk factors at the level of the practice, patient, tooth, and restoration on survival of direct class II restorations. Electronic patient files from 11 Dutch general practices were collected, and 31,472 restorations placed between January 2015 and October 2017 were analyzed. Kaplan-Meier statistics were performed; annual failure rates (AFRs) were calculated; and variables were assessed by multivariable Cox regression analysis. The observation time of restorations varied from 0 to 2.7 y, resulting in a mean AFR of 7.8% at 2 y. However, wide variation in AFRs existed among the operators, varying between 3.6% and 11.4%. A wide range of patient-related variables is related to a high risk for reintervention: patient age (elderly: hazard ratio [HR], 1.372), general health (medically compromised: HR, 1.478), periodontal status (periodontal problems: HR, 1.207), caries risk and risk for parafunctional habits (high: HR, 1.687), restorations in molar teeth (HR, 1.383), restorations placed in endodontically treated teeth (HR, 1.890), and multisurface restorations (≥4 surfaces: HR, 1.345). Restorations placed due to fracture were more prone to fail than restorations placed due to caries. When patient-related risk factors were excluded, remaining risk factors considerably changed in their effect and significance: the effect of operator, age of the patient, and endodontic treatment increased; the effect of the diagnosis decreased; and the socioeconomic status became significant (high: HR, 0.873). This study demonstrated that a wide variation of risk factors on the practice, patient, and tooth levels influences the survival of class II restorations. To provide personalized dental care, it is important to identify and record potential risk factors. Therefore, we recommend further clinical studies to include these patient risk factors in data collection and analysis.

Influence of Dental Prosthesis and Restorative Materials Interface on Oral Biofilms

Oral biofilms attach onto both teeth surfaces and dental material surfaces in oral cavities. In the meantime, oral biofilms are not only the pathogenesis of dental caries and periodontitis, but also secondary caries and peri-implantitis, which would lead to the failure of clinical treatments. The material surfaces exposed to oral conditions can influence pellicle coating, initial bacterial adhesion, and biofilm formation, due to their specific physical and chemical characteristics. To define the effect of physical and chemical characteristics of dental prosthesis and restorative material on oral biofilms, we discuss resin-based composites, glass ionomer cements, amalgams, dental alloys, ceramic, and dental implant material surface properties. In conclusion, each particular chemical composition (organic matrix, inorganic filler, fluoride, and various metallic ions) can enhance or inhibit biofilm formation. Irregular topography and rough surfaces provide favorable interface for bacterial colonization, protecting bacteria against shear forces during their initial reversible binding and biofilm formation. Moreover, the surface free energy, hydrophobicity, and surface-coating techniques, also have a significant influence on oral biofilms. However, controversies still exist in the current research for the different methods and models applied. In addition, more in situ studies are needed to clarify the role and mechanism of each surface parameter on oral biofilm development.

Dental Restoration Longevity among Geriatric and Special Needs Patients

INTRODUCTION

Although the population is aging and retaining more teeth, there is a lack of studies that address the longevity of dental restorations placed among older adults.

OBJECTIVES

This study aimed to describe the survival trajectory of dental restorations placed in an outpatient population of geriatric and adult special needs patients over a 15-y span, with particular interest in the longevity of subsequent restorations in teeth that received multiple restorations over time.

METHODS

Dental restorations of different types and sizes in patients aged ≥65 y treated between 2000 and 2014 at the University of Iowa College of Dentistry were followed until they incurred an event (i.e., restoration replacement, extraction of the tooth, or endodontic treatment of the tooth). Survival analysis and extended Cox regression models were used to generate hazard ratios for selected predictor variables.

RESULTS AND CONCLUSION

A total of 9,184 restorations were followed among 1,551 unique patients. During the follow-up period, 28.7% of these restorations incurred an event, and overall the restorations had a median life span of 6.2 y. In multivariable regression models, after controlling for sex and age, a greater number of restoration surfaces were associated with higher risks of failure, and the initial restoration recorded in the database for each participant tended to have a lower risk of failure than that of restorations that included any of those same surfaces that were placed later. This information could be helpful to older adult patients considering various restorative treatment options during the dental treatment-planning and informed consent process.

KNOWLEDGE TRANSFER STATEMENT

Informed decision making with regard to potential treatment options is an important component of health and well-being. The present study could contribute to the improved health of older adult dental patients by providing baseline information that clinicians can use as they discuss different restorative treatment options with these patients and their caregivers during the informed consent process.

A practice based longevity study on single-unit crowns

OBJECTIVES

This retrospective longitudinal study aimed to assess the longevity of single unit crowns placed by several dentists and to investigate risk factors associated with crown failures.

METHODS

From patient files, longevity of 3404 full crown restorations placed in 1557 patients by 8 Dutch dentists between 1996 and 2011 were analyzed. Annual failure rates (AFRs) were calculated and variables associated with failure (success and survival of crowns) were assessed by multivariate Cox-regressions analysis with shared frailty for patients.

RESULTS

Most of crowns were PFM (63.8%) placed in molars (58.1%) and non endodontically treated teeth (65.4%). The observation time of restorations varied from 3 weeks to 11 years with a mean of 7 years, resulting in a mean AFR at 11 years of 2.1% and 0.7% for success and survival of crowns, respectively. Among dentists a relevant variation for type of interventions was observed with AFR varying between 1.2% and 3.5%. The most significant risk factor for failure of crowns was the presence of an endodontic treatment, resulting in Hazard ratios of 1.31 for success [95%CI 1.07-1.61] and 1.89 [95%CI 1.35-2.65] for survival of crowns. Tooth type, tooth position (jaw) and gender showed also a significant influence on success of crowns. For survival, increase in patients' age results in a higher risk for failure.

CONCLUSIONS

Overall, crowns placed by a selected group of dentist showed a good to acceptable success and survival rates, mainly dependent from the practice. The presence of an endodontically treated tooth was a significant risk factor leading to more failures.