Influence of different clinical criteria on the decision to replace restorations in primary teeth

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.

Differential analysis of the dentin soluble proteomic

OBJECTIVES

To perform a differential analysis of the dentin soluble proteomic and assess the effects of tissue health state and protocol for protein extraction. We hypothesized the dentin soluble proteomic varies according to the tissue physiopathological state (intact vs. caries-affected) and protocol used to extract its proteins.

METHODS

Dentin from freshly extracted non-carious and carious teeth were randomly assigned for protein extraction using either guanidine-HCl/ethylenediaminetetraacetic acid (EDTA) or acetic acid. Protein extracts from intact and caries-affected dentin were processed and digested with trypsin for shotgun label-free proteomic analysis (nLC-ESI-MS/MS). Peptides identification was performed on a nanoACQUITY UPLC-Xevo Q-Tof MS system. Peptides identified with scores of confidence greater than 95% were included in the quantitative statistical analysis embedded in the PLGS software. Differences between experimental conditions were calculated using Student test-t with significance pre-set at α=0.05.

RESULTS

A total of 158 human proteins were identified. Approximately one-sixth of proteins (24/158) were present in at least two different extracts. Conversely, the greatest number of proteins (134/158) was identified uniquely in only one of the extracts. Overall, a larger number of soluble proteins was retrieved from caries-affected than intact dentin (86/158). Likewise, a greater number of proteins was extracted by the guanidine-HCl/EDTA (106/158) in comparison to acetic acid protocol. Several proteins detected in dentin extracts, mainly those from caries-affected teeth, are biological and/or metabolically involved with tissue turnover/remodeling.

CONCLUSION

The identity/abundance of soluble proteins retrieved from and remained in dentin noticeably depend on this tissue physiopathological state and protocol used to remove its minerals.

CLINICAL SIGNIFICANCE

The present findings brought new insight into the proteomic phenotype of human dentin and may provide targets for the development of novel caries disease-prevention therapies.

Determination of Water Content in Direct Resin Composites Using Coulometric Karl Fischer Titration

This study evaluated the water content and sorption of direct composites over 60 days using coulometric Karl Fischer titration (KFT). Plate-shaped specimens (10 × 10 × 1 mm³ of thickness) were built up using the composites Clearfil Majesty Posterior (CM), Grandio SO (GS), and Filtek Supreme XT (FS). Water contents were determined in non-stored specimens (control) or after storage in distilled water for up to 60 days (n = 5). The amount of water transferred from the specimens heated at 200 °C (isothermal mode) was measured in the Coulometer. The water content of non-stored specimens ranged from 0.28 to 1.69 wt% (5.6 to 31.2 μg/mm³) for GS and FS, respectively. The highest values of water sorption were observed for FS (25.3 μg/mm³ after 60 days). GS and CM showed similar water sorption after 60 days (≈9 μg/mm³), but an ultimate higher water content was observed for CM (0.9 wt%; 22.0 μg/mm³) than GS (0.7 wt%; 14.8 μg/mm³). Except for CM, no significant water sorption was observed between 21 and 60 days of storage. Since all composites presented some base water content, water sorption data alone do not account for the ultimate water content in direct resin-based composites.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Changes to dentin extracellular matrix following treatment with plant-based polyphenols

This study investigated whether treatment with plant-based polyphenols (PB-P) affected the biochemical and/or biomechanical properties of dentin extracellular matrix (ECM). Three PB-Ps were evaluated: luteolin (LT), galangin (GL), and proanthocyanidin (PAC). Because dentin ECM requires demineralization before treatment, this study also assessed the effect of these PB-Ps on dentin demineralized by two different chemicals. Dentin samples from extracted third molars were obtained, sectioned, and randomly assigned for demineralization with either phosphoric acid (PA) or ethylenediaminetetraacetic acid (EDTA). Following demineralization, baseline infrared (IR) spectra and apparent elastic modulus (AE) of each specimen were independently acquired. Based upon these initial tests, samples were randomly assigned to one of the PB-P treatments to ensure that distribution of baseline AE was similar across treatment groups. IR and AE specimens were individually immersed in either 0.2% LT, 0.4% GL or 1% PAC for 2 min. IR spectra of treated samples were compared to baseline IR spectra, looking for any interaction of PB-Ps with the demineralized dentin. The IR spectrum and AE of each PB-P-treated specimen were compared with their own correspondent baseline measurement. The ability of PB-Ps to inhibit proteolytic activity of dentin ECM was assessed by the hydroxyproline assay. Finally, the effect of PB-Ps on immediate bond strength of a dental adhesive to PA- or EDTA-etched dentin was also evaluated. PB-Ps exhibited distinctively binding affinity to dentin ECM and promoted significant increase in AE. PB-P treatment reduced the degradation rate of dentin ECM without causing detrimental effect on immediate bond strength to dentin. Our work represents the first-time that LT and GL have been assessed as dentin ECM biomodifiers.

The economic impact of two diagnostic strategies in the management of restorations in primary teeth: a health economic analysis plan for a trial-based economic evaluation

BACKGROUND

Different approaches have been used by dentists to base their decision. Among them, there are the aesthetical issues that may lead to more interventionist approaches. Indeed, using a more interventionist strategy (the World Dental Federation - FDI), more replacements tend to be indicated than using a minimally invasive one (based on the Caries Around Restorations and Sealants-CARS). Since the resources related to the long-term health effects of these strategies have not been explored, the economic impact of using the less-invasive strategy is still uncertain. Thus, this health economic analysis plan aims to describe methodologic approaches for conducting a trial-based economic evaluation that aims to assess whether a minimally invasive strategy is more efficient in allocating resources than the conventional strategy for managing restorations in primary teeth and extrapolating these findings to a longer time horizon.

METHODS

A trial-based economic evaluation will be conducted, including three cost-effectiveness analyses (CEA) and one cost-utility analysis (CUA). These analyses will be based on the main trial (CARDEC-03/ NCT03520309 ), in which children aged 3 to 10 were included and randomized to one of the diagnostic strategies (based on FDI or CARS). An examiner will assess children's restorations using the randomized strategy, and treatment will be recommended according to the same criteria. The time horizon for this study is 2 years, and we will adopt the societal perspective. The average costs per child for 24 months will be calculated. Three different cost-effectiveness analyses (CEA) will be performed. For CEAs, the effects will be the number of operative interventions (primary CEA analysis), the time to these new interventions, the percentage of patients who did not need new interventions in the follow-up, and changes in children's oral health-related quality of life (secondary analyses). For CUA, the effect will be tooth-related quality-adjusted life years (QALYs). Intention-to-treat analyses will be conducted. Finally, we will assess the difference when using the minimally invasive strategy for each health effect (∆effect) compared to the conventional strategy (based on FDI) as the reference strategy. The same will be calculated for related costs (∆cost). The discount rate of 5% will be applied for costs and effects. We will perform deterministic and probabilistic sensitivity analyses to handle uncertainties. The net benefit will be calculated, and acceptability curves plotted using different willingness-to-pay thresholds. Using Markov models, a longer-term economic evaluation will be carried out with trial results extrapolated over a primary tooth lifetime horizon.

DISCUSSION

The main trial is ongoing, and data collection is still not finished. Therefore, economic evaluation has not commenced. We hypothesize that conventional strategy will be associated with more need for replacements of restorations in primary molars. These replacements may lead to more reinterventions, leading to higher costs after 2 years. The health effects will be a crucial aspect to take into account when deciding whether the minimally invasive strategy will be more efficient in allocating resources than the conventional strategy when considering the management of restorations in primary teeth. Finally, patients/parents preferences and consequent utility values may also influence this final conclusion about the economic aspects of implementing the minimally invasive approach for managing restorations in clinical practice. Therefore, these trial-based economic evaluations may bring actual evidence of the economic impact of such interventions.

TRIAL REGISTRATION

NCT03520309 . Registered May 9, 2018. Economic evaluations (the focus of this plan) are not initiated at the moment.