Failure rates of class V restorations in the management of root caries in adults - a systematic review

Systematic review and network meta-analysis of restorative therapy and adhesive strategies in root caries lesions

AIM

This systematic review and network meta-analysis (NMA) aimed to establish a clinically relevant hierarchy of the different adhesive and/or restorative approaches to restore cavitated root caries lesions through the synthesis of available evidence.

MATERIALS AND METHODS

A systematic search was conducted in Medline/Web of Science/Embase/ Cochrane Library/Scopus/grey literature. RCTs investigating ≥2 restorative strategies (restorative /adhesive materials) for root caries lesions in adult patients were included. Risk of bias within studies was assessed (Cochrane_RoB-2) and the primary outcome was survival rate of restorations at different follow-up times (6-/12-/24-months). Network meta-analyses were conducted using a random effects model stratified by follow-up times. I2-statistics assessed the ratio of true to total variance in the observed effects. All available combinations of adhesives (1-SE: one-step self-etch; 2-3ER: two-/three-step etch-and-rinse) and restorative materials (conventional composite (CC) as well as conventional and resin-modified glass ionomer cements (GIC, RMGIC)) were included. Risk of bias across studies and confidence in NMA (CINeMA) were assessed.

RESULTS

547 studies were identified and nine were eligible for the NMA. In total, 1263 root caries lesions have been restored in 473 patients in the included clinical trials. Patients involved were either healthy (n = 6 trials), living in nursing homes (n = 1 trial) or received head-and-neck radiotherapy (n = 2 trials). There was statistically weak evidence to favour either of material/material combination regarding the survival rate. A tendency for higher survival rate (24-months) was observed for 2-3ER/CC (OR24mths 2.65; 95%CI=1.45/4.84) as well as RMGIC (OR24mths 2.05; 95%CI=1.17/3.61) compared to GIC. These findings were though not statistically significant and confidence of the NMA was low.

CONCLUSION

An evidence-based choice of restorative strategy for managing cavitated root caries lesions is currently impossible. There is a clear need for more standardised, well-designed RCTs evaluating the retention rate of root caries restoration approaches.

Clinical Investigation of the Inhibitory Effects of Tooth-Coating Materials on Initial Active Root Caries: A Pilot Randomized Controlled Trial

Background and Objectives: Caredyne ZIF-C is a novel, capsule-mixed zinc-containing prototype glass ionomer cement (GIC). Zinc ions are reported to inhibit root dentin demineralization, dentin collagen degradation, bacterial growth, acid production, and in vitro bacterial biofilm formation. However, the effectiveness of GICs against initial root caries lesions is unclear. Therefore, this study aimed to evaluate the efficacy of GICs, especially the new zinc-containing Caredyne ZIF-C GIC, as tooth-coating materials in patients with initial active root caries. Materials and Methods: A total of 58 lesions in 47 older adults (age > 65 years) were randomly allocated to one of the following three groups: Caredyne ZIF-C, Fuji VII (a conventional GIC), and sodium fluoride (NaF). All the lesions were treated with the assigned materials without removing the infected dentin, and the rates of dental plaque attachment and coating material fall-out were evaluated after 3, 6, and 12 months. The failure rate was defined as the number of teeth that needed restoration due to caries progression. Results: The plaque attachment rates tended to be lower in the material-coated root surfaces than in the healthy exposed root surfaces after 3, 6, and 12 months, although the differences among the three groups were not significant. Moreover, the coating material fall-out rate tended to be lower in the Caredyne ZIF-C group than in the Fuji VII group. There was no significant difference in the failure rate among the three groups at the 12 months mark. Conclusions: Though this pilot study offers a new direction for suppressing the progression of initial active root caries by controlling plaque attachment using GICs including Caredyne ZIF-C, clinical studies with a larger sample size are needed.

Retrospective Clinical Evaluation of RMGIC/GIC Class V Restorations

The aim of this retrospective study was to evaluate the clinical performance of glass-ionomer cement (GIC) and resin-modified glass-ionomer cement (RMGIC) materials in Class V carious cervical lesions restored by dental students. Ninety-six (96) restorations performed with either GIC (Fuji IX) (n = 39) or RMGIC (Fuji II LC) (n = 57) were evaluated using the modified USPHS criteria by two independent investigators at two follow-up evaluations (two years apart). The Fisher statistical test was used to compare USPHS criteria and examine significant differences, with a significance level set at p < 0.05. The Kaplan-Meier algorithm was used to calculate the survival probability. The overall success rate of Class V restorations was 72.9% at the second follow-up evaluation, with restorations ranging in age from 2.5 to 3.5 years. The RMGIC (Fuji II LC) restorations exhibited a significantly higher overall success rate compared to the GIC (Fuji IX) restorations (p = 0.0104). Significant differences were observed in retention (p = 0.0034) and color match (p = 0.0023).

Comparison of different bioglass applications on root caries – A laboratory-based study

The aim of this in-vitro study was to assess the effect of bioglass with different concentrations on root caries.

Ninety freshly-extracted teeth with root caries were randomly assigned to a single-use prophylaxis paste containing 15 % bioglass for 30 s with 1,450 ppmF toothpaste (15 % bioglass, n = 30), 1,450 ppmF toothpaste with 5 % bioglass (5 % bioglass, n = 30), and toothpaste containing 1,450 ppmF (Control, n = 30). Each sample received a standard brushing procedure for 10 s twice a day using the toothpastes. Teeth were immersed in remineralising solution with pH of 7 at 37 °C for 720 h. Surface roughness (Ra) was measured at baseline and after the application of the products at 0.5, 1, 4, 12, 24, 48, 168, 336 and 720 h. Subsequently, three samples from each group were randomly selected to measure calcium ion release over 15 h immersion in deionised water. These samples were then analysed using the SEM for the qualitative assessment of lesion topography. Repeated measures ANOVA, Wilcoxon paired tests and percentage changes were carried out to assess Ra. Calcium ion release data was analysed using one-way ANOVA and Tukey post-hoc tests.

After 720 h, 15 % bioglass had the highest decrease in Ra (Mean-difference = 1.502 µm, p = 0.001), then 5 % bioglass (Mean-difference = 0.723 µm, p = 0.09) whereas the control had the lowest Ra decrease (Mean-difference = 0.518 µm, p = 0.55). The differences in Ra between the groups were highly significant (p < 0.001). The cumulative calcium ion release was significantly high for the 5 % bioglass in comparison to the 15 % bioglass, whilst the control had the lowest release (p < 0.001). SEM analysis showed the presence of bioglass particles only on 15 % bioglass samples.

The use of prophylaxis paste with 15 % bioglass and 1,450 ppmF toothpaste was promising to reverse/arrest root caries when compared to the toothpaste containing 1,450 ppmF with 5 % bioglass for a period of 30 days.

Clinical effects of laser-based cavity preparation on class V resin-composite fillings

The aim of the present clinically controlled two-year study was to investigate the influence of laser-based cavity preparation on the long-term performance of Class V resin-composite fillings. Class V non-carious lesions (n = 75) were randomly assigned to two test and one control group. Cavities in both test groups were prepared using an Er,Cr:YSGG laser (Waterlase MD, Biolase, Irvine, California, USA). The device was operated at 3 W (150 mJ, 30 J/cm²), 50% water, 60% air, 30 Hz in H mode. Subsequently, laser-prepared tooth surfaces in test group I (n = 21) were additionally conditioned by acid etching (etch-and-rinse). Laser-prepared cavities of test group II (n = 21) received no additional acid conditioning. After application of an adhesive, all cavities were restored using the resin-composite Venus®. For cavities in the control group (n = 33) conventional diamond burs were used for preparation which was followed by an etch-and-rinse step, too. The fillings were evaluated immediately (baseline) and after 6, 12 and 24 months of wear according to the C-criteria of the USPHS-compatible CPM-index. The results showed that after 24 month of wear, laser-preparation was associated with fillings of high clinical acceptability. Compared to conventional bur-based treatment, laser-based cavity preparation resulted in fillings with high marginal integrity and superior marginal ledge configurations (p = 0.003). Furthermore, laser-preparation combined with additional acid-conditioning (test group I) resulted in fillings with the best marginal integrity and the lowest number in marginal discoloration, especially at the enamel-composite margins (p = 0.044). In addition, total loss of fillings was also less frequently observed in both laser groups as compared to the control. The results clearly demonstrate that laser-based cavity preparation will benefit the clinical long-time performance of Class V resin-composite fillings. Furthermore, additional acid-conditioning after laser preparation is of advantage.

Caries Management in Special Care Dentistry

The objective of this article is to provide a summary of the current evidence-based recommendations for caries management in patients with special health care needs (SHCNs). Considerations regarding caries risk assessment and preventive measures are also discussed with the goal of helping clinicians to manage the caries disease process using a person-centered approach and risk-based interventions. Importantly, most of the evidence is still based on the general population, because the evidence for those with SHCNs is still limited.

Development of 4-META/MMA-TBB resin with added benzalkonium chloride or cetylpyridinium chloride as antimicrobial restorative materials for root caries

To develop antimicrobial restorative materials for root caries, we assessed a 4-META/MMA-TBB resin (Bondfill SB Plus, Sun Medical) containing benzalkonium chloride (BAC) or cetylpyridinium chloride (CPC) at 1.25, 2.5, and 5.0 wt%. The same resin without antibacterial agent was used as control. The degree of conversion was measured by attenuated total reflectance-Fourier transform infrared spectroscopy. The 3-point flexural strength test was conducted according to ISO 4049. The antimicrobial effect against three oral bacteria (Streptococcus mutans, S. sobrinus, and Actinomyces naeslundii) was assessed using agar diffusion tests. The shear bond strength to root dentin was assessed after 24 h of storage in water with or without 10,000 thermal cycles. The shear bond strength data were statistically compared using a linear mixed-effects model (α = 0.05). The specimen with 5.0 wt% BAC showed a significantly higher degree of conversion than the control, but it also had significantly lower flexural strength and lower shear bond strength after thermal cycling than the other specimens. When BAC or CPC was added at ≥ 2.5 wt%, the resins inhibited the growth of the three investigated microbes. In conclusion, both BAC and CPC showed significant antimicrobial effects when added at 5.0 wt% to the 4-META/MMA-TBB resin. Up to 2.5 wt%, neither antimicrobial agent affected the degree of conversion, flexural strength, or shear bond strength of the resin.

Effect of dentifrice slurry abrasivity and erosive challenge on simulated non-carious cervical lesions development in vitro

PURPOSE

To investigate the effect of slurry abrasive levels and acidic challenges on the development of non-carious cervical lesions.

METHODS

Ninety-six extracted upper premolars were affixed in pairs to acrylic blocks and had their root surfaces covered by acrylic resin except for 2 mm from the cemento-enamel junction. The specimens were distributed into six groups (n = 8 pairs) based on two experimental factors: (1) slurry abrasivity level [low/medium/high] and (2) citric acid challenge [yes/no]. Specimens were brushed for 5,000, 15,000, 35,000, and 65,000 strokes. Volume loss (VL) was determined based on optical profilometry scans of specimens impressions at the baseline and at subsequent brushing levels. Data were analyzed using repeated measures analysis of variance and Bonferroni pairwise comparison (α = 0.05).

RESULTS

Higher VL values were associated with high-abrasivity slurries relative to low- and medium-abrasivity slurries (P < 0.001). Increasing the slurry abrasivity level increased the VL regardless of the acidic challenge, which did not have a significant effect (P = 0.184). After 65,000 strokes, significant VL was recorded in all groups relative to preceding brushing levels (P < 0.001).

CONCLUSION

Higher values of time-dependent surface loss were associated with increased dentifrice slurry abrasivity, regardless of the citric acid challenge.

Root Caries Preventive Effect of Varnishes Containing Fluoride or Fluoride + Chlorhexidine/Cetylpyridinium Chloride In Vitro

Caries preventive varnishes containing only fluoride might differ from those containing a combination of fluoride and antimicrobial components in terms of mineralization properties and their impact on the cariogenic biofilm. We compared a fluoride and a fluoride + chlorhexidine (CHX)/cetylpyridinium chloride (CPC) varnish on root caries formation in vitro. One hundred bovine root dentin samples were allocated to five groups (n = 20/group): (1) 7700 ppm fluoride varnish (Fluorprotector S (F)), (2) experimental placebo varnish for F (F-P), (3) 1400 ppm fluoride + 0.3% CHX/0.5% CPC varnish (Cervitec F (CF)), (4) experimental placebo varnish for CF (CF-P), (5) untreated control. Cariogenic challenge was provided using a multi-station, continuous-culture 3-species (Streptococcus mutans (SM), Lactobacillus rhamnosus (LR), Actinomyces naeslundii (AN)) biofilm model for 10 days. Mineral loss (ΔZ) was evaluated using transversal microradiography and bacterial counts in the biofilm assessed as colony-forming units. Fluorescence in situ hybridization (FISH) and confocal microscopy were performed to assess the three-dimensional biofilm architecture. Mean ± SD (vol% × μm) ΔZ was significantly lower for F (9133 ± 758) and CF (9835 ± 1677) compared to control (11362 ± 919) (p < 0.05), without significant differences between F and CF. SM counts were significantly lower and LR counts significantly higher in F- and CF-biofilms compared to control. AN counts were significantly higher in the F-biofilms than in all other groups. According to FISH, SM and LR invaded dentinal tubules only in the control-group. In the CF-group, the basal biofilm layer did not contain SM and AN. Both F and CF varnishes had similar caries-preventive effects and a considerable impact on biofilm structure and composition.

Tests to detect and inform the diagnosis of root caries

BACKGROUND

Root caries is a well-recognised disease, with increasing prevalence as populations age and retain more of their natural teeth into later life. Like coronal caries, root caries can be associated with pain, discomfort, tooth loss, and contribute significantly to poorer oral health-related quality of life in the elderly. Supplementing the visual-tactile examination could prove beneficial in improving the accuracy of early detection and diagnosis. The detection of root caries lesions at an early stage in the disease continuum can inform diagnosis and lead to targeted preventive therapies and lesion arrest.

OBJECTIVES

To assess the diagnostic test accuracy of index tests for the detection and diagnosis of root caries in adults, used alone or in combination with other tests.

SEARCH METHODS

Cochrane Oral Health's Information Specialist undertook a search of the following databases: MEDLINE Ovid (1946 to 31 December 2018); Embase Ovid (1980 to 31 December 2018); US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov, to 31 December 2018); and the World Health Organization International Clinical Trials Registry Platform (to 31 December 2018). We studied reference lists as well as published systematic review articles.

SELECTION CRITERIA

We included diagnostic accuracy study designs that compared one or more index tests (laser fluorescence, radiographs, visual examination, electronic caries monitor (ECM), transillumination), either independently or in combination, with a reference standard. This included prospective studies that evaluated the diagnostic accuracy of single index tests and studies that directly compared two or more index tests. In vitro and in vivo studies were eligible for inclusion but studies that artificially created carious lesions were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently and in duplicate using a standardised data extraction and quality assessment form based on the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) specific to the review context. Estimates of diagnostic test accuracy were expressed as sensitivity and specificity with 95% confidence intervals (CI) for each dataset. We planned to use hierarchical models for data synthesis and explore potential sources of heterogeneity through meta-regression.

MAIN RESULTS

Four cross-sectional diagnostic test accuracy studies providing eight datasets with data from 4997 root surfaces were analysed. Two in vitro studies evaluated secondary root caries lesions on extracted teeth and two in vivo studies evaluated primary root caries lesions within the oral cavity. Four studies evaluated laser fluorescence and reported estimates of sensitivity ranging from 0.50 to 0.81 and specificity ranging from 0.40 to 0.80. Two studies evaluated radiographs and reported estimates of sensitivity ranging from 0.40 to 0.63 and specificity ranging from 0.31 to 0.80. One study evaluated visual examination and reported sensitivity of 0.75 (95% CI 0.48 to 0.93) and specificity of 0.38 (95% CI 0.14 to 0.68). One study evaluated the accuracy of radiograph and visual examination in combination and reported sensitivity of 0.81 (95% CI 0.54 to 0.96) and specificity of 0.54 (95% CI 0.25 to 0.81). Given the small number of studies and important differences in the clinical and methodological characteristics of the studies we were unable to pool the results. Consequently, we were unable to formally evaluate the comparative accuracy of the different tests considered in this review. Using QUADAS-2 we judged all four studies to be at overall high risk of bias, but only two to have applicability concerns (patient selection domain). Reasons included bias in the selection process, use of post hoc (data driven) positivity thresholds, use of an imperfect reference standard, and use of extracted teeth. We downgraded the certainty of the evidence due to study limitations and serious imprecision of the results (downgraded two levels), and judged the certainty of the evidence to be very low.

AUTHORS' CONCLUSIONS

Visual-tactile examination is the mainstay of root caries detection and diagnosis; however, due to the paucity of the evidence base and the very low certainty of the evidence we were unable to determine the additional benefit of adjunctive diagnostic tests for the detection and diagnosis of root caries.

Basic properties of novel S-PRG filler-containing cement

This study was aimed to evaluate the effect of a novel surface pre-reacted glass-ionomer (S-PRG) filler-containing cement for root caries. We prepared the cements using five different S-PRG filler amounts (0, 10, 20, 30, and 40 wt%). Compressive strength, ion release, acid buffering capacity, and microstructure of the as-prepared cements were evaluated. The compressive strength was statistically significant; it was highest for 0 wt% S-PRG cement. Ion release in 0 wt% S-PRG was highest for F^- and Al, whereas in 40 wt% S-PRG it was highest for B. For 20, 30, and 40 wt% S-PRG cements, Na and Sr release was higher compared to the other ions. The acid buffering capacity was significantly higher in the 40 wt% S-PRG cement than in the others. In the microstructural analysis, no difference of surface structure was observed among each of the S-PRG filler contents (0-40 wt% S-PRG).

Can We Predict Usage of Dental Services? An Analysis from Germany 2000 to 2015

OBJECTIVES

We aimed to predict the usage of dental services in Germany from 2000 to 2015 based on epidemiologic and demographic data, and to compare these predictions against claims within the statutory health insurance.

METHODS

Indicators for operative (number of coronally decayed or filled teeth, root surface caries lesions, and fillings), prosthetic (number of missing teeth), and periodontal treatment needs (number of teeth with probing pocket depths (PPDs) ≥ 4 mm) from nationally representative German Oral Health Studies (1997, 2005, 2014) were cross-sectionally interpolated across age and time, and combined with year- and age-specific population estimates. These, as well as the number of children eligible for individual preventive services (aged 6 to 17 y), were adjusted for age- and time-specific insurance status and services' utilization to yield predicted usage of operative, prosthetic, periodontal, and preventive services. Cumulative annual usage in these 4 services groups were compared against aggregations of a total of 24 claims positions from the statutory German health insurance.

RESULTS

Morbidity, utilization, and demography were highly dynamic across age groups and over time. Despite improvements of individual oral health, predicted usage of dental services did not decrease over time, but increased mainly due to usage shifts from younger (shrinking) to older (growing) age groups. Predicted usage of operative services increased between 2000 and 2015 (from 52 million to 56 million, +7.8%); predictions largely agreed with claimed services (root mean square error [RMSE] 1.9 million services, error range -4.6/+3.8%). Prosthetic services increased (from 2.4 million to 2.6 million, +11.9%), with near perfect agreement to claimed data [RMSE 0.1 million services, error range -8.3/+3.9%]). Periodontal services also increased (from 21 million to 27 million, +25.9%; RMSE 5.2 million services, error range +21.9/+36.5%), as did preventive services (from 22 million to 27 million, +20.4%; RMSE 3 million, error range -13.7/-4.7%).

CONCLUSION

Predicting dental services seems viable when accounting for the joint dynamics of morbidity, utilization, and demographics.

KNOWLEDGE TRANSFER STATEMENT

Based on epidemiologic and demographic data, predicting usage of certain dental services is viable when accounting for the dynamics of morbidity, utilization, and demographics.

Surgical extrusion of a maxillary premolar after orthodontic extrusion: a retrospective study

Objectives

Crown-root fracture and cervical caries in maxillary premolars constitute a challenge in cases of subgingival placement of restoration margins. Surgical extrusion has been practiced successfully in permanent anterior teeth. The aim of the present retrospective study was to assess the clinical outcome of surgical extrusion after orthodontic extrusion in maxillary premolars.

Materials and Methods

Twenty-one single, tapered root maxillary premolars with subgingival crown-root fracture or caries were included. Presurgical orthodontic extrusion was performed on all teeth to prevent root resorption. Extent of extrusion and rotation was determined based on crown/root ratio. The postoperative splinting period was 7 to 14 days. Clinical and radiographic examination was performed at an interval of 1, 2, and 3 months.

Results

After the mean follow-up of 41.9±15.2 months, failure was observed as increased mobility in 3 of 21 cases. No significant difference was observed in the outcome of surgical extrusion based on tooth type, age, sex, 180° rotation, or time for extraction. Furthermore, marginal bone loss was not observed.

Conclusion

Surgical extrusion of maxillary premolars can be a possible therapeutic option in cases of subgingival crown-root fracture.

How to Intervene in the Root Caries Process? Systematic Review and Meta-Analyses

The aim of this review as part of the preparation for a workshop organized by the European Federation of Conservative Dentistry (EFCD) in conjunction with the European Organisation for Caries Research (ORCA) was to systematically analyze available evidence of non-, micro- as well as invasive interventions for root caries lesions (RCLs). For each treatment strategy, a separate systematic review was either performed (micro-invasive and choice of restorative material) or updated (non-invasive and excavation technique) each of them following PRISMA guidelines, and if possible meta-analyses were performed. Besides the general advice to improve tooth brushing with fluoride toothpaste main findings for non-invasive interventions in RCLs, the use of dentifrices containing 5,000 ppm F- as well as professionally applied chlorhexidine varnish or silver diamine fluoride seemed to be more efficacious to arrest root caries compared to conventional fluoride toothpaste or placebo respectively. However, this conclusion is based only on a few randomized clinical trials. For micro-invasive treatments, only 2 studies focusing on sealants were available without clear conclusions. A recent review on the comparison of atraumatic restorative treatment compared with conventional treatment concluded that there is insufficient data to clearly rule out if any difference with regard to restoration longevity between both techniques exists. When restoring coventionally, composites performed better than resin-modified and glass ionomer cements. However, all materials showed rather high annual failure rates in the majority of the studies and evidence is based on a low number of prospective studies with a rather high risk of bias.

Atraumatic vs conventional restorative treatment for root caries lesions in older patients: Meta- and trial sequential analysis

OBJECTIVES

We aimed to appraise the comparative clinical efficacy of atraumatic restorative treatment (ART) versus conventional restorative treatment (CT) using a meta-analysis, and assessed the robustness of evidence by trial sequential analysis (TSA).

BACKGROUND

Due to its simplified clinical approach, ART may be advantageous over CT for restoration of root caries lesions in institutionalised older patients.

METHODS

Three electronic databases (PubMed, Embase and Cochrane CENTRAL) were screened, and hand searches and cross-referencing performed to identify randomised controlled trials reporting on survival of ART vs CT for restoration of root caries in older patients. Trial selection, data extraction and risk of bias assessment were performed by two independent reviewers. ART and CT were compared using fixed- or random-effects pairwise meta-analysis for per-protocol (PP), intention-to-treat (ITT) and best-case scenarios. TSA was used to control for risk of random errors.

RESULTS

A total of 235 studies were identified, and three trials involving 130 patients (463 restorations) were included. Risk of bias was high or moderate in all but one trial. ART was associated with a significantly increased risk of failure (OR [95% CI] 2.06 [1.06/4.00]) in PP- but not in ITT analysis (1.36 [0.92/2.02]). Analyses for best-case scenarios found great uncertainty introduced by attrition. No firm evidence was reached according to TSA.

CONCLUSIONS

For restoration of root caries, there is insufficient data to clearly rule out whether differences between ART and CT exist. Limited available data indicate there might be an increased risk of failure for ART.

Combining Bioactive Multifunctional Dental Composite with PAMAM for Root Dentin Remineralization

Objectives. The objectives of this study were to: (1) develop a bioactive multifunctional composite (BMC) via nanoparticles of amorphous calcium phosphate (NACP), 2-methacryloyloxyethyl phosphorylcholine (MPC), dimethylaminohexadecyl methacrylate (DMAHDM) and nanoparticles of silver (NAg); and (2) investigate the effects of combined BMC + poly (amido amine) (PAMAM) on remineralization of demineralized root dentin in a cyclic artificial saliva/lactic acid environment for the first time. Methods. Root dentin specimens were prepared and demineralized with 37% phosphoric acid for 15 s. Four groups were prepared: (1) root dentin control; (2) root dentin with BMC; (3) root dentin with PAMAM; (4) root dentin with BMC + PAMAM. Specimens were treated with a cyclic artificial saliva/lactic acid regimen for 21 days. Calcium (Ca) and phosphate (P) ion concentrations and acid neutralization were determined. The remineralized root dentin specimens were examined via hardness testing and scanning electron microscopy (SEM). Results. Mechanical properties of BMC were similar to commercial control composites (p = 0.913). BMC had excellent Ca and P ion release and acid-neutralization capability. BMC or PAMAM alone each achieved slight mineral regeneration in demineralized root dentin. The combined BMC + PAMAM induced the greatest root dentin remineralization, and increased the hardness of pre-demineralized root dentin to match that of healthy root dentin (p = 0.521). Significance. The excellent root dentin remineralization effects of BMC + PAMAM were demonstrated for the first time. BMC + PAMAM induced effective and complete root dentin remineralization in an acid challenge environment. The novel BMC + PAMAM method is promising for Class V and other restorations to remineralize and protect tooth structures.

Evaluation of Biodentine in the Restoration of Root Caries

There is no “gold-standard” material for the operative management of root caries. The aim of this study was to determine if the clinical performance of Biodentine would be acceptable for the restoration of root caries in older adults. A randomized controlled clinical trial was conducted comparing a calcium silicate cement (Biodentine), a high-viscosity glass ionomer cement (Fuji IX GP Extra), and a resin-modified glass ionomer cement (Fuji II LC). Of the 334 volunteers assessed for eligibility, 249 were excluded. A total of 303 lesions in 85 participants were randomized, with 151 lesions allocated to receive Biodentine, 77 to Fuji IX GP Extra, and 77 to Fuji II LC. Patients were reviewed by a calibrated dentist who was not involved in restoration placement and who was blinded to material allocation. Restorations were assessed according to a modified US Public Health Service criteria. The cumulative survival percentages after 6 mo and 1 y were 58.6% and 47.2% in the Biodentine group, 89.6% and 83.8% in the Fuji IX GP Extra group, and 89.5% and 84.9% in the Fuji II LC group, respectively. There were statistically significant differences ( χ2 test, P < 0.001) in restoration failure rates between restoration groups. There was no difference between Fuji IX GP Extra and Fuji II LC, but differences ( P < 0.001) were shown between the Fuji II GP Extra group and the Biodentine group and also between the Fuji II LC group and the Biodentine group at both time points. Based on the results of this study, Biodentine cannot be recommended for the operative management of root caries. Fuji IX GP Extra and Fuji II LC displayed similar success rates, and high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option for the restoration of root caries ( ClinicalTrials.gov NCT01866059).

Knowledge Transfer Statement: The results of this study can assist dental practitioners when selecting a restorative material for the operative management of root caries. This randomized controlled trial compared the 1-y clinical performance of a calcium silicate–based material to that of a high-viscosity glass ionomer cement and a resin-modified glass ionomer cement in the operative management of root caries. The study concluded that high-viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option to dental practitioners when restoring the root surface.