When to intervene in the caries process? A Delphi consensus statement

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

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

Preventive management of carious lesions: from non-invasive to micro-invasive operative interventions

Understanding that dental carious lesions occur as a result of the action of micro-organisms in the dental plaque biofilm, where demineralisation on the tooth surface is the first sign of the disease, such incipient lesions can be treated using preventive, non-operative and minimally invasive operative dentistry. If the caries process is left unmanaged, the lesions progress towards cavitation, leading to more invasive treatments. This article discusses the principles of preventive, non-invasive and micro-invasive treatments of early carious lesions, outlining the clinical situations where these therapies can be applied.

In vitro remineralization of adjacent interproximal enamel carious lesions in primary molars using a bioactive bulk-fill composite

BACKGROUND

Surface remineralization is recommended for the management of active non-cavitated interproximal carious lesions in primary teeth. According to the American Academy of Pediatric Dentistry, a recently recognized category of materials called bioactive restorative materials can be used for remineralization. This study aimed to evaluate the release of fluoride (F), calcium (Ca) and phosphate (P) ions from Predicta® Bioactive Bulk-fill composite compared with EQUIA Forte® and Filtek™ Z350 and to determine the remineralization effect of these 3 restorative materials on adjacent initial interproximal enamel carious lesions.

METHODS

The release of F, Ca and P ions from 3 groups ((n = 10/group) (Group 1- Predicta®, Group 2- EQUIA Forte® and Group 3- Filtek™ Z350)) was determined at 1st, 4th, 7th and 14th days. After creating artificial carious lesions, human enamel samples were randomly assigned into 3 groups (n = 13/group) which were placed in contact with occluso-proximal restorative materials and exposed to a 14-day pH cycling period. Surface microhardness was determined using a Knoop microhardness assay at baseline, after artificial carious lesions formation and after pH cycling. The difference in the percentage of surface microhardness recovery (%SMHR) among groups was compared. Mineral deposition was analyzed with energy-dispersive x-ray spectroscopy (EDS) and the enamel surface morphology was evaluated with scanning electron microscopy (SEM). Kruskal-Wallis's test with Dunn's post hoc test and one-way ANOVA with Tukey's post hoc test were used for data analysis.

RESULTS

EQUIA Forte® released the highest cumulative amount of F and P ions, followed by Predicta® and Filtek™ Z350. Predicta® released higher amount of Ca ions than EQUIA Forte® and Filtek™ Z350. Predicta® demonstrated the highest %SMHR, followed by EQUIA Forte® and Filtek™ Z350. There was a significant difference in the %SMHR between Predicta® and Filtek™ Z350 (p < 0.05). However, EQUIA Forte® demonstrated the highest fluoride content, followed by Predicta® and Filtek™ Z350. The SEM images of EQUIA Forte® and Predicta® revealed the greater mineral deposition.

CONCLUSION

Predicta® demonstrated a marked increase in surface microhardness and fluoride content of adjacent initial interproximal enamel carious lesions in primary molars compared with Filtek™ Z350. Predicta® is an alternative restorative material to remineralize adjacent initial interproximal enamel carious lesions in primary molars, especially in high-risk caries patients.

Cost-effectiveness and Acceptance in Children and Parents of the Hall Technique: Systematic Review of Clinical Trials

AIMS

The purpose of this systematic review was to evaluate the cost-effectiveness and acceptance of children and their parents of the Hall technique (HT) for dental rehabilitation in pediatric dentistry.

BACKGROUND

The approach of the HT is that of minimally invasive treatment of the dental element and is used exclusively on primary molars. Various studies in the literature point to HT as a restorative option well accepted by children and parents and quite predictable, with low retreatment rates and good cost-effectiveness for the management of primary molars with carious lesions. However, no systematic review in the literature has approached randomized clinical trials on these topics to produce a high level of evidence and help establish clinical HT protocols.

REVIEW RESULTS

Eight articles were selected for the systematic review. The HT was more cost-effective than procedures using other restorative materials. Regarding acceptance, in terms of esthetics, high percentages of satisfaction were reported for parents and children, with a divergence between studies in the comparison of esthetic preference with atraumatic restorative treatment. However, when considering crown cementation pain, comfort, anxiety, preference, and satisfaction, the HT was generally better evaluated when compared to other restorative materials.

CONCLUSION

The HT is an excellent restorative option when considering cost-effectiveness and acceptance and is recommended for use in daily clinical practice.

CLINICAL SIGNIFICANCE

Results indicate that HT is superior to other restorative materials regarding its acceptance by children and parents in terms of pain, comfort, anxiety, and crown preference and satisfaction. There were also high percentages of satisfaction with esthetics. Hall technique may initially appear expensive for dentists, but its effectiveness over time and the lesser need for consultations and reinventions ensure better cost-benefit than other restorative materials. How to cite this article: Valentim FB, Moreira KMS, Carneiro VC, et al. Cost-effectiveness and Acceptance in Children and Parents of the Hall Technique: Systematic Review of Clinical Trials. J Contemp Dent Pract 2023;24(12):1016-1025.

Framework for fiscal impact analysis of managing initial caries lesions with noninvasive therapies

BACKGROUND

Evidence-based noninvasive caries therapies for initial caries lesions are available in the United States. Fundamental differences between noninvasive therapies and the traditional surgical dental approach warrant a study of the financial scalability.

METHODS

The financial costs and benefits of fee-for-service clinics and payors were compared across 11 scenarios simulating the treatment of 1,000 initial caries lesions during a 3-year period. The scenarios included varying combinations of noninvasive therapies (that is, silver diamine fluoride, self-assembling peptide P11-4, and glass ionomer therapeutic sealants), no treatment, and various rates of 1- through 3-surface restorations to an estimated 2022 practice model. We used a decision tree microsimulation model for deterministic and probabilistic sensitivity analyses. We derived assumptions from an initial lesion and noninvasive therapy-focused cohort study with operations data from 16 sites accepting Medicaid in Alabama as a case study and clinical data from all 92 sites.

RESULTS

In comparison with the 2022 practice model assumed for this study, scenarios that produce mutually beneficial results for payors' savings and clinics' net profits and profit margins include self-assembling peptide P11-4, silver diamine fluoride on nonesthetic surfaces, and a mix of 3 noninvasive therapies. When considering the limited resources of chair and clinician time, the same scenarios, as well as silver diamine fluoride with restorations, emerged with substantially higher clinic net profit.

CONCLUSIONS

Hypothetical scenarios that include noninvasive therapies and minimize restorations achieve improved outcomes for all parties.

PRACTICAL IMPLICATIONS

Payors and clinicians should explore and implement noninvasive caries therapies to improve oral health for all. This study was registered at ClinicalTrials.gov. The registration number is NCT04933331.

Systematic review and meta-analysis on the effect of self-assembling peptide P11-4 on arrest, cavitation, and progression of initial caries lesions

BACKGROUND

Simple noninvasive evidence-based interventions for caries are needed to overcome limitations in the restorative paradigm. The self-assembling peptide P₁₁-4 is a noninvasive intervention that regenerates enamel in initial caries lesions.

STUDIES REVIEWED

The authors conducted a systematic review and meta-analysis on the effectiveness of the P₁₁-4 products Curodont Repair (Credentis; now manufactured by vVARDIS) (CR) and Curodont Repair Fluoride Plus (Credentis; now manufactured by vVARDIS) on initial caries lesions. Primary outcomes were lesion progression after 24 months, caries arrest, and cavitation. Secondary outcomes were changes in merged International Caries Detection and Assessment System score categories, quantitative light-induced fluorescence (QLF; Inspektor Research System), esthetic appearance, and lesion size.

RESULTS

Six clinical trials met the inclusion criteria. Results of this review represent 2 primary and 2 secondary outcomes. When compared with parallel groups, use of CR likely results in a large increase in caries arrest (relative risk [RR], 1.82 [95% CI, 1.32 to 2.50]; 45% attributable risk [95% CI, 24% to 60%]; number needed to treat [NNT], 2.8) and likely decreases lesion size by a mean (SD) of 32% (28%). The evidence also suggests that use of CR results in a large reduction in cavitation (RR, 0.32 [95% CI, 0.10 to 1.06]; NNT, 6.9) and is uncertain about lowering merged International Caries Detection and Assessment System score (RR, 3.68 [95% CI, 0.42 to 32.3]; NNT, 19). No studies used Curodont Repair Fluoride Plus. No studies reported adverse esthetic changes.

PRACTICAL IMPLICATIONS

CR likely has clinically important effects on caries arrest and decreased lesion size. Two trials had nonmasked assessors, and all trials had elevated risks of bias. The authors recommend conducting longer trials. CR is a promising treatment for initial caries lesions. The protocol for this systematic review was registered a priori with PROSPERO (304794).

Classification of a patient's caries activity based on lesion activity assessment among adults: findings from a prospective cohort study

OBJECTIVE

To investigate whether the classification of a patient's caries activity based on lesion activity assessment can predict the increment and progression of coronal and root caries lesions among adults.

METHODS

This population-based prospective cohort study followed 413 individuals (mean age 54.1) from southern Brazil for 4 years. Data collection included a questionnaire and clinical examination to record coronal/root caries and gingival recession. The main outcomes were caries increment measured as decayed, missing and filled tooth surfaces (DMFS) and caries progression (surface-level analysis). The main predictor variable was patients' caries activity at baseline ("caries-inactive" or "caries-active"). Negative binomial regression models (unadjusted and adjusted) were used.

RESULTS

Caries-active individuals were more likely to present DMFS increment than caries-inactive ones when migrations among DMFS components were considered (IRR [incidence risk ratio] = 1.26, 95%CI [confidence interval] = 1.01-1.58). On the other hand, no such association was found when these migrations were disregarded. The risk for coronal caries progression on filled surfaces was 90% higher among caries-active patients (IRR=1.9; 95%CI=1.4-2.6). In addition, patient's caries activity was able to predict higher risk for root caries progression in newly exposed root surfaces (IRR=1.9; 95%CI=1.0-3.6).

CONCLUSION

The classification of a patient's caries activity based on lesion activity was able to foresee lesion progression on the coronal and root surfaces more susceptible to caries among adults. Clinical relevance Classifying a patient's caries activity is a useful tool for the clinical management of dental caries in adults.

Comparison of calcium-based technologies to remineralise enamel subsurface lesions using microradiography and microhardness

Assessment of enamel subsurface lesion remineralisation is essential for the evaluation of novel remineralisation technologies. The gold standard to assess subsurface mineral gain of enamel lesions is transverse microradiography (TMR). However, some studies have utilised surface microhardness (SMH) to evaluate efficacy of remineralisation agents. The aim of this study was to assess remineralisation of enamel subsurface lesions using TMR and SMH after in vitro treatment with calcium-containing technologies, and to test correlation between the TMR and SMH measurements. The parameters obtained from the TMR and SMH analyses of enamel subsurface remineralisation were not significantly correlated. Furthermore, the enamel subsurface remineralisation as measured by TMR was significantly correlated with the water-soluble calcium concentration of the remineralisation products. Scanning electron microscopy revealed surface precipitates formed by specific remineralisation treatments obfuscated accurate assessment of remineralisation by SMH. It was concluded that TMR is a more appropriate method for analysis of enamel subsurface remineralisation, and that SMH values of remineralised enamel should be interpreted with caution. Using TMR the level of remineralisation (%R) by the different technologies was CPP-ACP/F (31.3 ± 1.4%); CPP-ACP (24.2 ± 1.4%); CaSO₄/K₂HPO₄/F (21.3 ± 1.4%); f-TCP/F (20.9 ± 1.0%); Nano-HA/F (16.3 ± 0.3%); Nano-HA (15.3 ± 0.6%) and F alone control (15.4 ± 1.3%).

When Less is More: Minimally Invasive, Evidence-Based Treatments for Dentine Caries in Primary Teeth - The Hall Technique and Silver Diamine Fluoride

Evidence supports minimally invasive dentistry, and we have a better understanding of dental caries as a biofilm-mediated disease. These factors, together with the current need to reduce aerosol generation, make treatment approaches such as the Hall Technique and the use of silver diamine fluoride (SDF) more relevant than ever.Successful treatment planning depends on carious lesions being detected, their status accurately assessed, and a correct diagnosis made. Choosing the most appropriate treatment options for the tooth and child relies on marrying this with a precise history and an understanding of indications and contraindications for treatments.This article outlines the optimal use of the Hall Technique and SDF, allowing dental practitioners and therapists to use these modalities as less invasive approaches to provide the highest quality treatment for children with dental caries; less is more.

Agreement of Bioluminescence Measurements and Visual Assessment in Monitoring Occlusal Surfaces of Permanent Teeth

Background: Caries lesion activity is typically assessed by visual–tactile criteria. Regular monitoring is required to detect the transition of lesions and to ensure that the initial assessment was valid. This clinical study aimed to evaluate the agreement of bioluminescence measurements (Calcivis imaging system, Cis) with visual examination to assess caries lesion activity and to monitor occlusal surfaces. Methods: The occlusal surfaces of ninety-one permanent posterior teeth were assessed for the presence or absence of active caries lesions with ICCMS criteria and Cis measurements at three visit times: baseline (t1) and six months (t2) and 12 months (t3) after baseline. Results: At the baseline visit, 70% of the included occlusal sites were assessed visually as active lesions (ICCMS codes 1 and 2). At t3, 64.8% of the sites showed signs of an active lesion. The percentage agreements between the visual and Cis methods were 87.8% (t1), 89.9% (t2) and 88.6% (t3). The corresponding κ-values were 0.71 (95% CI 0.52;0.87), 0.75 (95% CI 0.59;0.89) and 0.77 (95% CI 0.61;0.90), respectively. No significant difference between the visual and bioluminescence systems was found at any visit (p > 0.05). The results based on cluster randomization (generalized estimation equations) showed no significant differences between the visual and Cis findings for all visits (p = 0.108, Wald Χ² with 1 df = 2.587). Conclusion: The bioluminescence system demonstrated substantial agreement for the activity assessment of occlusal lesions compared to the findings obtained by visual assessment over twelve months.

Fissure sealing and caries development in Norwegian children

PURPOSE

To explore the use of fissure sealing as a caries preventive method by describing characteristics of children who had received sealants and to study associations between sealing and caries prevalence at 12 years of age.

METHODS

The study included 3075 children examined at 5 and 12 years of age. Data were collected by clinical examination and questionnaire to parents. The questionnaire provided information on child characteristics and oral health behaviour in children at 5 years of age. Data on sealing and caries prevalence were obtained from dental records. Bi- and multivariate logistic regressions were performed. The Regional Committee for Medical Research Ethics approved the study (2.200.54 and 2013/1881).

RESULTS

Of the children, 12% had received sealants on permanent teeth before 12 years of age. Children with dentin caries at 5 years of age (OR 2.0, CI 1.5-2.7) had a higher probability of having received sealants than children without caries. Having sealants (OR 2.8, CI 2.2-3.6), enamel caries (OR 1.5, CI 1.2-1.9), dentin caries (OR 2.9, CI 2.3-3.6) and using fluoride lozenges less than daily (OR 1.5, CI 1.3-1.8) at 5 years of age were associated with having dentin caries prevalence at 12 years of age.

CONCLUSION

Few children had received fissure sealing. Although sealing was used as a caries preventive method in children who had experienced caries in primary teeth, these children continued developing caries in their permanent teeth.

Commercially Available Ion-Releasing Dental Materials and Cavitated Carious Lesions: Clinical Treatment Options

The contemporary approach for operative caries management emphasizes personalized interventions for each patient, dependent upon the individual's caries susceptibility/risk, the stage of the carious lesion and its activity. The clinician's challenge is to optimize the extent of cavity preparation and the choice of dental restorative biomaterials, appreciating the benefits offered by ion-releasing restorative materials. There is a growing application of bioactive/bio-interactive materials in minimally invasive operative dentistry, as they may help with tissue recovery by ion release. In case of moderate or extensive occlusal cavitation, the clinical criteria include the individual caries susceptibility and carious lesion activity. In high caries risk cases, ion-releasing biomaterials (IRB) can be used, as well as for active carious lesions. In proximal lesions, the clinical criteria include the individual caries susceptibility, the lesion activity and presence of cavities with little or no enamel at the gingival margin. This article aims to discuss the restorative ion-releasing options, according to different clinical situations, and the caries susceptibility to manage cavitated carious lesions in permanent adult teeth.

Nonrestorative Management of Dental Caries

The World Dental Federation (FDI) policy statement in 2016 advocated evidence-based caries-control measures for managing dental caries. The caries management philosophy has shifted from the traditional surgical manners to minimal intervention dentistry. Minimal intervention dentistry aims to extend the longevity of natural teeth. It places the nonrestorative approaches as a priority. The nonrestorative approaches for caries management aim to tackle the etiological factors of dental caries. Caries can be prevented or reversed by restricting the sugar intake and its frequency in the diet, improving oral hygiene practices, and using fluoride toothpaste. This article aims to present strategies for the nonrestorative management of dental caries, which are divided into four components to address the different etiological factors of dental caries. The first component is controlling dental plaque. Strategies for plaque control include oral hygiene instruction, motivational interviewing, mechanical plaque control, and chemical plaque control. The second component for nonrestorative management is reducing the risk of caries by identifying caries risk factors and protective factors, assessing personal caries risk, and customizing a treatment plan. Evidence-based measures for caries prevention include using fluoride, and dental sealants should be provided. The third component includes topical treatment to remineralise early carious lesions. The last component is long-term follow-up. Appropriate strategy adoption for the nonrestorative management of dental caries prolongs the life span of the teeth and sustains the good oral health of patients.

Current Novel Caries Diagnostic Technologies: Restorative Dentists' Attitude and Use Preferences

Early detection of caries lesions is key to a successful restorative dental treatment plan. The aim of this study was to investigate the preferences and attitude of graduate restorative dentistry residents (RDRs) regarding novel caries diagnostic technologies (NCDT) and to provide a brief overview of available technologies for both specialized and general dental practice. This cross-sectional study used an online questionnaire (17 questions) concerning RDRs’ attitude, preferences, and insights regarding five available NCDTs. It was distributed among twenty RDRs at a local government dental school following a review session about NCDTs. Collected responses were analyzed statistically using one-way analysis of variance (ANOVA), chi-squared with Bonferroni correction, and Kruskal-Wallis tests at a 0.05 significance level. Sixty-five percent of RDRs reported an interest in NCDTs as a discussion topic and almost half of them were positive towards their use, however, sixty percent of respondents were hesitant to diagnose caries solely using NCDTs. Fiber-optic-transillumination (FOTI) systems were ranked the best overall and with regard to all the investigated criteria (p < 0.05). Chosen reasons for FOTI included price followed by ease of use. In general, high price rated as the most perceived reason for not choosing a given NCDT followed by low practical applicability. Meanwhile, ease of use followed by relevant application ranked as the main reported reasons to choose an NCDTs.