Occlusal Caries Management: Preferences among Dentists in Norway

Fissure Sealants or Fluoride Varnish? A Randomized Pragmatic Split-Mouth Trial

This study aimed to compare the clinical effectiveness of resin-based fissure sealants (FS) and fluoride varnish (FV) in children at high caries risk. A practice-based split-mouth randomized clinical trial was conducted at 9 Public Dental Service (PDS) clinics in Norway. In total, 409 children age 6 to 10 y at high caries risk (d3mft > 0) meeting inclusion criteria were recruited by dentists and dental hygienists during routine examination. Eligibility criteria were 2 fully erupted first permanent molars (FPMs) in the same jaw, with sound occlusal surfaces or with initial caries. Participation was voluntary, caregivers and eligible children were informed about the study, and written parental consent was obtained. FS and FV were randomly applied on contralateral FPMs in the same jaw, with each participant serving as their own control. FS was applied at baseline and thereafter maintained according to clinicians' conventional procedures, whereas FV was applied at baseline, 6 mo, and 12 mo. The study outcome was success, with no need for invasive treatment (caries control), while failure was defined as dentin carious lesion or restoration. Two-level mixed-effects logistic regression analysis was used to compare FS and FV groups. Of 409 recruited children, 369 (90%) children/tooth pairs were examined after 36 mo. Intention-to-treat analysis showed 94.1% adjusted predicted probability (aPP) of success (95% confidence interval [CI] 91.7 to 96.4) in the FS group and 89.6% aPP (95% CI 86.5 to 92.7) in the FV group. In the adjusted analysis, the FV group had a lower OR for success compared with the FS group (OR 0.54, 95% CI 0.24 to 0.87). In the population studied, the clinical effectiveness of FS was statistically significantly higher compared with FV but below the estimated minimal clinically important difference of 10%.

In vivo effectiveness of visual inspection and laser fluorescence in the diagnosis of early pit-and-fissure carious lesions: A cross-sectional study in a group of Romanian children

General practitioners are still facing great challenges in the management of occlusal caries. Therefore, the development of better diagnostic protocols and assessment of caries activity might improve the results of nonoperative treatment. This study aimed to evaluate the effectiveness of visual inspection based on ICDAS-II (International Caries Detection and Assessment System) and DiagnoDent pen in the detection of pit-and-fissure early lesions in young permanent molars. The evaluation of 237 occlusal surfaces and caries risk assessment were performed in 96 children aged 7 to 15 years. The presence of pit-and-fissure noncavitated lesions was recorded using ICDAS-II scoring system and laser fluorescence. Statistical analysis was performed using McNemar test, with a level of significance of P < .05. The caries risk was measured for all participants. In 109 occlusal surfaces both methods identified enamel changes (46%) and in 62 cases both methods excluded the carious lesion (26.2%). The statistical analysis showed a significant moderate agreement between ICDAS-II code and DiagnoDent pen measurements (McNemar chi-squared statistic 9.5, P = .002 and Cohen kappa coefficient = 0.427). The majority of children (69.8%) had moderate caries risk and the most frequent risk factors recorded were sugar intake between meals, lack of regular dental control and poor oral hygiene. We concluded that ICDAS-II is a valuable and reliable diagnostic tool for early pit-and-fissure lesions and could be used alone during dental examination in children. The evaluation of caries risk should become clinical routine, as parameters belonging to high risk were frequently recorded in our study group.

Polymer-based dental filling materials placed during pregnancy and risk to the foetus

Background

Tooth-coloured polymer-based dental filling materials are currently the first choice for dental restorative treatment in many countries. However, there are some concerns about their safety. It has been shown that substances known as endocrine disrupters, which might pass through the placental barrier, are released from these materials within the first hours after curing. Thus, the placement of polymer-based dental fillings in pregnant women may put the vulnerable foetus at risk. Large epidemiological studies exploring the risk of having polymer-based dental materials placed during pregnancy are lacking. The aim of this study was to investigate the association between the placement of polymer-based dental fillings during pregnancy and adverse birth outcomes.

Methods

This study is based on data from the large Norwegian Mother and Child Cohort Study (MoBa). The information about dental treatment during pregnancy was obtained from questionnaires sent to the participating women during weeks 17 and 30 of pregnancy. Reported placement of “white fillings” was used as exposure marker for having received polymer-based dental filling materials. Only singleton births were included in the present study. Data were linked to the Medical Birth Registry of Norway. Logistic regression models that included the mother’s age, level of education, body mass index, parity, and smoking and alcohol consumption during pregnancy were used to estimate the odds ratio (OR) and 95% confidence interval (CI). Different adverse birth outcomes were of interest in the present study.

Results

Valid data were available from 90,886 pregnancies. Dentist consultation during pregnancy was reported by 33,727 women, 10,972 of whom had white fillings placed. The adjusted logistic regression models showed no statistically significant association between having white dental fillings placed during pregnancy and stillbirth, malformations, preterm births, and low or high birth weight.

Conclusions

In this study, women who reported white fillings placed during pregnancy had no increased risk for adverse birth outcomes compared with women who did not consult a dentist during pregnancy. Thus, our findings do not support the hypothesis of an association between placement of polymer-based fillings during pregnancy and adverse birth outcomes.

Minimally Invasive Intervention for Primary Caries Lesions: Are Dentists Implementing This Concept?

Contemporary minimally invasive treatment concepts for restorative treatment of primary caries lesions include both delayed intervention and smaller-sized preparations restricted to removal of carious tissue. The aim of this study was to investigate whether these concepts have resulted in a trend towards a more conservative choice made by dentists regarding treatment thresholds and restorative techniques. The results from previously conducted, precoded questionnaires developed by Espelid and Tveit, as well as from a recent Dutch questionnaire, were collected and analysed. A worldwide trend towards more minimally invasive strategies in the operative treatment of caries lesions could not be observed, neither for the initiation of operative treatment nor for the preparation techniques. However, in some countries, changes over time could be assessed, especially in Norway, where a reduction in the proportion of interventions is visible for both occlusal and approximal lesions, indicating that more dentists are postponing interventions until the lesions have progressed to a deeper level. From the Dutch national survey, it could be concluded that operators that intervene at an earlier stage of approximal lesioning (stage ≤4) also intervene at an earlier stage of occlusal caries (stage ≤3) (p = 0.012; OR = 2.52; 95% CI: 1.22-5.22). Generally, it can be concluded that dentists worldwide still tend to operatively intervene at a too early stage of caries, although variations exist between countries. A worldwide shift could be observed in the restorative material applied, since composite resin has almost completely replaced amalgam for restoring primary caries lesions.

Clinical Diagnosis of Dental Caries in the 21st Century: Introductory Paper - ORCA Saturday Afternoon Symposium, 2016

Classifications employed to measure dental caries should first of all reflect the dynamics of the disease, in order to provide a solid basis for subsequent treatment decisions and for further monitoring of dental health of individual patients and populations. The contemporary philosophy of dental caries management implies that nonoperative treatment of caries lesions should be implemented whenever possible, limiting operative interventions to the severe and irreversible cases. The ORCA Saturday Afternoon Symposium 2016, held back-to-back to the 63rd ORCA Congress in Athens, Greece, was intended to provide an update on general requirements for clinical caries diagnosis and to overview caries diagnostic classifications including their rationale, validation, advantages, and limitations. Clinical caries diagnostic criteria and caries management outcomes are interrelated, and any diagnostic classification disregarding this concept is outdated, according to the current understanding of oral health care. Choosing clinical caries diagnostic classifications that assess the activity status of detected lesions should be a priority for dental professionals since these classifications favor the best clinical practice directed towards nonoperative interventions. The choice of clinical caries diagnostic classifications in research, in clinical practice, and in public health services should be guided by the best available scientific evidence. The clinical caries diagnostic classifications should be universally applicable in all these fields. Policy making in oral health care and the underlying policy analyses should follow the same standards. Any clinical caries diagnostic classification disregarding the universality of its use is of limited or no interest in the context of the clinical caries diagnosis of today.

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

BACKGROUND

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

AIM

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Diagnosis, Risk Assessment, and Treatment Decisions for Occlusal Caries: A Survey from the Danish Public Dental Health Service

This study validates a case-based survey method and analyzes the extent to which Danish dental professionals apply current concepts and strategies for occlusal caries management in children, adolescents, and young adults. A case-based, precoded questionnaire consisting of 10 clinical cases/patients with 26 teeth/occlusal surfaces was developed. The cases were set up in a PowerPoint presentation and color printed as a booklet illustrating patients with different patterns of caries activity, severity, and risk. A total of 69 dental professionals participated. Content and face validity of the survey method was established using a panel of experts. The panel also assessed the reliability of the method using a test-retest procedure (κ ≥ 0.80) and acting as benchmark. Measurements of agreement between dental professional and benchmark assessments showed substantial agreement for overall caries activity and risk assessment of patients and for clinical and radiographic severity of occlusal lesions (κ = 0.61-0.67). For assessment of caries lesion activity on occlusal surfaces, the agreement was moderate (κ = 0.50). Regarding treatment decisions, dental professionals showed substantial agreement when indicating restorative treatments (κ = 0.68). Multivariate logistic regression analysis showed a significant influence of various patient-, lesion-, and participant-related variables in the assessment of caries risk, caries activity and severity, and treatment decision. In conclusion, Danish dental professionals participating in the study apply reasonably well current concepts on overall caries activity and risk assessment, clinical and radiographic severity of occlusal lesions, and, to a certain extent, assessment of caries lesion activity on occlusal surfaces. Nonoperative treatment decisions had a high priority among Danish professionals.

Occlusal Caries: Biological Approach for Its Diagnosis and Management

The management of occlusal caries still remains a major challenge for researchers as well as for general practitioners. The present paper reviews and discusses the most up-to-date knowledge and evidence of the biological principles guiding diagnosis, risk assessment, and management of the caries process on occlusal surfaces. In addition, it considers the whole spectrum of the caries process on occlusal surfaces, ranging from the molecular ecology of occlusal biofilms to the management of deep occlusal caries lesions. Studies using molecular methods with focus on biofilms in relation to occlusal caries should explore the relationship between the function and the structural composition of these biofilms to understand the role of occlusal biofilms in caries development. State-of-the-art measures to evaluate risk for occlusal caries lesion activity, caries incidence, and progression should include the assessment of the occlusal biofilm and the stage of tooth eruption. Careful clinical examination of non-cavitated lesions, including assessment of the lesion activity status, remains the major tool to determine the immediate treatment need and to follow on the non-operative treatment outcome. Even medium occlusal caries lesions in the permanent dentition may be treated by non-invasive fissure sealing. By extending the criteria for non-invasive treatments, traditional restoration of occlusal surfaces can be postponed or even avoided, and the dental health in children and adolescents can be improved. Selective removal (incomplete) to soft dentin in deep carious lesions has greater success rates than stepwise excavation. Selective (complete) removal to firm dentin has a lower success rate due to increased pulp exposure.

Ten-Year Survival of Class II Restorations Placed by General Practitioners

The aim of this retrospective practice-based study was to investigate the survival of direct class II restorations placed by a group of general dental practitioners (GDPs) and to analyze the effect of practice-, patient-, and tooth/restoration-related factors. Electronic patient files of 24 general dental practices were used for collecting the data for this study. From the patient files, survival rates of 222,836 composites, amalgams, glass ionomers, and compomers placed in 61,121 patients by 67 GDPs between 1999 and 2011 were analyzed by Kaplan-Meier statistics and a multiple Cox regression. The investigated group of GDPs placed restorations with a satisfactory survival (mean AFR₁₀, 4.9%; 95% confidence interval, 2.1 to 7.7), although a wide variation in annual failure rate (AFR) existed between the different operators, varying between 2.6% and 7.0%. Restorations placed in young adults (21-30 y old) survived longest, whereas they showed a shorter survival in children (hazard ratio [HR], 1.553) and the elderly (HR, 1.593). Restorations in molar teeth, restorations placed in endodontically treated teeth, and multisurface restorations are more at risk for reintervention. However, restoration size (included surfaces) has a greater impact on restoration survival in premolar teeth. For the future, improved data collection at the practice/operator, patient, and tooth/restoration level (e.g., risk assessment and diagnoses) will provide the opportunity to evaluate even more extensively the risk factors involved. Knowledge Transfer Statement: The results of this study give insight into the long-term survival of direct dental restorations and the influencing practice-, patient-, and tooth/restoration-related variables.