How to Intervene in the Caries Process: Dentin Caries in Primary Teeth

Performance of restorations in primary molars over a seven-year period

OBJECTIVE

The aim of this study was to evaluate the use and reintervention rate of fillings compared to preformed metal crowns in the everyday clinical practice of German dentists.

METHODS

In this retrospective, longitudinal analysis, fee codes from the Kassenzahnärztliche Vereinigung Westfalen-Lippe for restorations placed in primary molars between 2012 and 2015 in children until 7 years of age followed for a 7-year period (latest until December 2022) were filtered and analyzed with the Fine and Gray competing risk regression and Cox proportional hazards regression to calculate the risk of reintervention divided into the main outcomes "Successful", "Minor Failure/Repair" and "Major Failure/Endodontic Treatment/Extraction". 367,139 primary molars (one-surface fillings: n = 117,721; two-surface fillings n = 198,815; three-surface fillings n = 36,695; more than three-surface fillings n = 8,267 and preformed metal crowns n = 5,641 were included in this study.

RESULTS

Teeth treated with preformed crowns needed significantly less re-interventions. Subdistribution hazard ratio for minor events was 0.117 (95 %-CI: 0.097 to 0.141) and hazard ratio of major events (HR=0.786; 95 %-CI: 0.695 to 0.890) when compared to one-surface fillings in multivariable adjusted analysis. Within 7-year follow-up preformed crowns required less repairs (80.6 % success rate, minor failure 4.4 %, major failure 16.3 %) than the teeth treated with composite fillings (46.2 %-52.6 % success rate, minor failure 27.0 %-39.5 %, major failure 15.5 %-28.4 %, p < 0.001).

CONCLUSION

Within the German healthcare system fillings are the first choice for treating primary molars despite considerably higher reintervention rates. This encourages a discussion on the indication of fillings and the more durable preformed metal crowns to reduce unnecessary reintervention in young children.

CLINICAL SIGNIFICANCE

This study gives an unprecedented insight into the German healthcare system regarding the reintervention rates of the most relevant treatment techniques for caries in primary molars.

ORCA-EFCD consensus report on clinical recommendation for caries diagnosis. Paper I: caries lesion detection and depth assessment

OBJECTIVES

The aim of the present consensus paper was to provide recommendations for clinical practice considering the use of visual examination, dental radiography and adjunct methods for primary caries detection.

MATERIALS AND METHODS

The executive councils of the European Organisation for Caries Research (ORCA) and the European Federation of Conservative Dentistry (EFCD) nominated ten experts each to join the expert panel. The steering committee formed three work groups that were asked to provide recommendations on (1) caries detection and diagnostic methods, (2) caries activity assessment and (3) forming individualised caries diagnoses. The experts responsible for "caries detection and diagnostic methods" searched and evaluated the relevant literature, drafted this manuscript and made provisional consensus recommendations. These recommendations were discussed and refined during the structured process in the whole work group. Finally, the agreement for each recommendation was determined using an anonymous Delphi survey.

RESULTS

Recommendations (N = 8) were approved and agreed upon by the whole expert panel: visual examination (N = 3), dental radiography (N = 3) and additional diagnostic methods (N = 2). While the quality of evidence was found to be heterogeneous, all recommendations were agreed upon by the expert panel.

CONCLUSION

Visual examination is recommended as the first-choice method for the detection and assessment of caries lesions on accessible surfaces. Intraoral radiography, preferably bitewing, is recommended as an additional method. Adjunct, non-ionising radiation methods might also be useful in certain clinical situations.

CLINICAL RELEVANCE

The expert panel merged evidence from the scientific literature with practical considerations and provided recommendations for their use in daily dental practice.

Evaluating Glass Ionomer Cement Longevity in the Primary and Permanent Teeth-An Umbrella Review

The aim of this umbrella review was to evaluate the longevity of glass ionomer cement (GIC) as a restorative material for primary and permanent teeth. Research in the literature was conducted in three databases (MedLine/PubMed, Web of Science, and Scopus). The inclusion criteria were: (1) to be a systematic review of clinical trials that (2) evaluated the clinical longevity of GICs as a restorative material in primary and/or permanent teeth; the exclusion criteria were: (1) not being a systematic review of clinical trials; (2) not evaluating longevity/clinical performance of GICs as a restorative material; and (3) studies of dental restorative materials in teeth with enamel alterations, root caries, and non-carious cervical lesions. Twenty-four eligible articles were identified, and 13 were included. The follow-up periods ranged from 6 months to 6 years. Different types of GICs were evaluated in the included studies: resin-modified glass ionomer cement (RMGIC), compomers, and low- and high-viscosity glass ionomer cement. Some studies compared amalgam and composite resins to GICs regarding longevity/clinical performance. Analyzing the AMSTAR-2 results, none of the articles had positive criteria in all the evaluated requisites, and none of the articles had an a priori design. The criteria considered for the analysis of the risk of bias of the included studies were evaluated through the ROBIS tool, and the results of this analysis showed that seven studies had a low risk of bias; three studies had positive results in all criteria except for one criterion of unclear risk; and two studies showed a high risk of bias. GRADE tool was used to determine the quality of evidence; for the degree of recommendations, all studies were classified as Class II, meaning there was still conflicting evidence on the clinical performance/longevity of GICs and their recommendations compared to other materials. The level of evidence was classified as Level B, meaning that the data were obtained from less robust meta-analyses and single randomized clinical trials. To the best of our knowledge, this is the first umbrella review approaching GIC in permanent teeth. GICs are a good choice in both dentitions, but primary dentition presents more evidence, especially regarding the atraumatic restorative treatment (ART) technique. Within the limitation of this study, it is still questionable if GIC is a good restorative material in the medium/long term for permanent and primary dentition. Many of the included studies presented a high risk of bias and low quality. The techniques, type of GIC, type of cavity, and operator experience highly influence clinical performance. Thus, clinical decision-making should be based on the dental practitioner's ability, each case analysis, and the patient's wishes. More evidence is needed to determine which is the best material for definitive restorations in permanent and primary dentition.

Silver Diamine Fluoride Renaissance in Paediatric Dentistry: A 24-Month Retrospective and Cross-Sectional Analysis

Background and Objectives: Silver diamine fluoride (SDF) has been incorporated into the treatment of dental caries in children, mainly in countries with high caries prevalence. In Europe, however, SDF started to gain popularity during the COVID-19 pandemic. This study aimed to investigate the efficacy of SDF and to evaluate dentists'/parents' acceptance of SDF use in paediatric patients treated in a German university setting. Materials and Methods: A retrospective analysis of all patients treated with SDF between 2017 and 2020 was carried out. Only teeth with no reported clinical/radiographic evidence of irreversible pulpal inflammation were included. The outcome measures were success, minor failures (caries progression, reversible pulpitis) and major failures (irreversible pulpitis, abscess). The treatment acceptance by dentists and the parents of SDF-treated children was cross-sectionally evaluated using questionnaires. Descriptive statistics and Kaplan-Meier survival analysis were performed. Results: A total of 93 patients (mean age 5.3 ± 2.9 years) with 455 treated teeth (418 primary/91.9%; 37 permanent/8.1%) were included and followed up for up to 24 months (19.9 ± 10.5 months). SDF was used for dental caries (98.2%) and hypersensitivity relief on MIH teeth (1.8%). Most teeth did not show any failure (total success 84.2%). A total of 5 teeth (1.1%) showed minor failures, and 67 teeth (14.7%) showed major failures (p = 0.001). Success/failure rates were not affected by patient compliance, gender, dentition, or operator (p > 0.05). In total, 30 questionnaires were collected from parents (mean age 36.8 ± 6.4 years). SDF was applied on anterior (n = 2/6.7%), posterior (n = 15/50%) and anterior/posterior teeth (n = 13/43.3%). At the 1-week follow-up, 80% of parents noticed black teeth discoloration. Treatment satisfaction was higher for posterior (95.2%) than for anterior teeth (36.4%; p < 0.001). In the 27 responses from clinicians, SDF was generally considered a viable option in paediatric dentistry (n = 23; 85%). Conclusions: SDF was found to be effective and well-accepted by parents and dentists for caries inactivation in a paediatric dentistry German university setting.

Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association

BACKGROUND

An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth.

TYPES OF STUDIES REVIEWED

The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations.

RESULTS

The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios.

PRACTICAL IMPLICATIONS

The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.

The revolutionary evolution in carious lesion management

Contemporary paradigms of dental caries management focus on the biological approaches to treating the disease and its principal symptom, the carious lesion. This narrative review traces the evolution of carious lesion management from the operative and invasive approaches of G. V. Black's era to the current period of minimally invasive biological approaches. The paper explains the rationale for adopting biological approaches to dental caries management and lists the five core principles of this management approach. The paper also details the aims, features, and the most recent evidence base for the different biological carious lesion management approaches. Based on current practice guidelines, collated clinical pathways for lesion management are also presented in the paper to aid clinicians in their decision-making. It is hoped that the biological rationale and evidence summarized in this paper will bolster the shift to modern biological carious lesion management approaches among dental practitioners.

Hall technique for primary teeth: A systematic review and meta-analysis

Background

There has been a debate about the use of Hall Technique (HT), whether it can be considered as a standard technique for the management of carious primary molars.

Aim

To summarise the evidence on HT for managing dentine caries in primary teeth.

Design

MEDLINE, Embase, CENTRAL and Epistemonikos databases were searched for clinical studies conducted from 2007 to 2021 evaluating HT in primary teeth. Two reviewers independently screened, data extracted and quality assessed the studies.

Results

Eleven publications from eight unique studies were included. Four were of low risk of bias overall and five studies were included in a meta-analysis. Overall, HT was 49 % (RR 1.49 [95 % CI: 1.15–1.93], I² =89.5 %, p < 0.001) more likely to succeed. When compared to direct restorations, HT was 80 % more likely to succeed; while similar success was found when compared to conventional preformed metal crowns. HT was also over 6 times (RR 0.16 [95 %CI: 0.10–0.27], I² =0 %, p < 0.001) less likely to fail. Most of the studies included proximal or multi-surface lesions.

Conclusions

HT is successful option for the management of caries in primary teeth, particularly for proximal or multi-surface dentine lesions. It is well-tolerated by children and acceptable to parent, with mild adverse effects reported.

Comparative evaluation of the fracture resistance of newly developed prefabricated fibreglass crowns and zirconium crowns

BACKGROUND

Prefabricated fibreglass crowns (PFCs) require less tooth structure reduction than prefabricated zirconium crowns (PZCs) for restoring primary molars. Little is known, however, about their mechanical properties.

AIM

To investigate the fatigue survival and fracture resistance of PZCs and PFCs cemented with two different types of luting cement [glass-ionomer cement (GIC) and resin-modified GIC (RMGIC)].

DESIGN

One hundred and twenty extracted human primary molars were randomly divided into subgroups (n = 15) according to the crown type (PFCs/PZCs), the luting cement (GIC/RMGIC) and crowns subjected to the chewing simulation test with thermocycling mechanical loading (CSTTML). The surfaces of the teeth were reduced by approximately 2 mm in the PZC group and 1 mm in the PFC group. All the samples were subjected to fracture tests.

RESULTS

None of the samples subjected to CSTTML exhibited signs of surface damage, fracture or premature debonding. The forces required to fracture PFCs were higher than those required for PZCs in all groups (p = .001). The highest mean fracture resistance values were obtained from the group of PFCs cemented with GIC that were subjected to the CSTTML (2515.8 N ± 619.2 N).

CONCLUSIONS

PFCs presented high fatigue survival and could be used as alternatives to PZCs as they require less tooth structure reduction. Crowns cemented with GIC had a similar fracture resistance value when compared with RMGIC.

Clinical Effectiveness of Restorative Materials for the Restoration of Carious Primary Teeth: An Umbrella Review

Since untreated dental caries remain a worldwide burden, this umbrella review aimed to assess the quality of evidence on the clinical effectiveness of different restorative materials for the treatment of carious primary teeth. A literature search in electronic bibliographic databases was performed to find systematic reviews with at least two-arm comparisons between restorative materials and a follow-up period ≥12 months. Reviews retrieved were screened; those eligible were selected, and the degree of overlap was calculated using the 'corrected covered area' (CCA). Data were extracted and the risk of bias was assessed using the ROBIS tool. Fourteen systematic reviews with a moderate overlap (6% CCA) were included. All materials studied performed similarly and were equally efficient for the restoration of carious primary teeth. Amalgam and resin composite had the lowest mean failure rate at 24 months while high-viscosity and metal-reinforced glass ionomer cements had the highest. At 36 months, high-viscosity glass ionomer cements showed the highest failure rate with compomer showing the lowest. Most reviews had an unclear risk of bias. Within the limitations of the review, all materials have acceptable mean failure rates and could be recommended for the restoration of carious primary teeth.

Review on Preformed Crowns in Pediatric Dentistry—The Composition and Application

The purpose of this review is to compare and contrast the various types of preformed crowns that can be used to restore the primary teeth in children. Historically, preformed crowns have been widely available for the past 50 years. The clinical performance of preformed crowns has evolved to meet higher functional, mechanical, and aesthetic demands. Preformed crowns are available in a range of prefabricated sizes and shapes. Preformed crowns can vary depending on their properties, compounds, methods of preparation, and biocompatibility.

A comparison of the mechanical proprieties of different types of primary tooth restorations: an in vitro study

OBJECTIVE

To compare the different restoration types of primary teeth to determine which type is appropriate for extensive caries of primary molars and incisors based on mechanical properties.

MATERIALS AND METHODS

A total of 160 primary teeth were evaluated in this study, including 80 incisors and 80 molars. Each category was divided into four groups: the control group, composite resin group, pre-veneered stainless steel crown (stainless steel crown) group, and zirconia crown group. Compressive strength test and fatigue strength test were performed.

RESULTS

The compressive strength and fatigue strength of the composite resin group were significantly decreased compared with the control group (P < 0.05). The prefabricated crown groups showed increased fatigue and compressive strength compared with the control group, and the zirconia crown group was higher than that of the pre-veneered stainless steel crown group (P < 0.05). The zirconia crown group was less than the stainless steel crown group (P < 0.05) in the compressive strength but more than the stainless steel crown group (P < 0.05) in the fatigue strength.

CONCLUSIONS

The compressive strength and fatigue strength of crown restoration were superior to that of the composite resin filling. The fatigue strength of the zirconia crown also performed better than the pre-veneered stainless steel crown and the stainless steel crown. The compressive strength of the zirconia crown was less than that of the stainless steel crown.

CLINICAL RELEVANCE

The zirconia crown is a new restoration method for primary teeth that may be commonly applied in clinical practice.

A 12-Month Randomized Clinical Trial of 38% SDF vs. Restorative Treatment

PURPOSE

The aim of this 2-arm, parallel-group, 12-mo randomized clinical trial was to compare the effectiveness of semiannual application of 38% silver diamine fluoride (SDF) versus restorative treatment (RT) to manage cavitated caries lesions in primary teeth in a diverse population of children in Michigan.

METHODS

Children aged 2 to 10 y with at least 1 soft cavitated lesion (International Caries Detection and Assessment System 5 or 6) with no pain or signs/symptoms of irreversible pulpitis were recruited and randomly assigned to 2 intervention groups. One random lesion per child received 38% SDF (twice, at a 6-mo interval) or RT. All interventions and assessments were done by calibrated dentists. Primary outcome measures were clinical failure rates: minor (e.g., reversible pulpitis, active/soft lesion or progression, restoration loss or need for replacement/repair, secondary caries) and major (e.g., irreversible pulpitis, abscess, extraction). Parent, child, and provider acceptability was also assessed.

RESULTS

Ninety-eight children were enrolled and randomized, with a mean (SD) age of 4.8 y (1.8); 46% were female and their mean dmft + DMFT was 6.3 (3.9). Sixty-nine children were assessed at 12 mo (sample was within the planned 30% attrition rate). There were significantly more teeth with minor failures (SDF = 65%, RT = 23%, P ≤ 0.001) and major failures (SDF = 13%, RT = 3%, P ≤ 0.001) in the SDF group than the RT group; 74% of SDF-treated lesions were hard at 12 mo vs. 57% at 6 mo. Providers stated that SDF was easier, faster, and more preferable than RT (P ≤ 0.001). No significant differences were found in parental satisfaction and acceptability. At 12 mo, children in the RT arm felt significantly (P < 0.05) happier with their tooth appearance and stated that their visit to the dentist hurt less.

CONCLUSION

At 12 mo, SDF-treated lesions had significantly more minor and major failures than RT, suggesting that SDF-treated teeth need to be closely monitored in a population at high caries risk (ClinicalTrials.gov NCT02601833).

KNOWLEDGE OF TRANSFER STATEMENT

The results of this study can be used by clinicians when deciding whether to restore or apply silver diamine fluoride to cavitated lesions in primary teeth. Information on treatment outcomes and parent, child, and provider acceptability can help guide appropriate treatment decisions and need for monitoring.

Minimal intervention dentistry for managing carious lesions into dentine in primary teeth: an umbrella review

PURPOSE

This umbrella review systematically appraised published systematic reviews on Minimal Intervention Dentistry interventions carried out to manage dentine carious primary teeth to determine how best to translate the available evidence into practice, and to provide recommendations for what requires further research.

METHOD

An experienced information specialist searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the NIHR Journals Library. In addition, the PROSPERO database was searched to identify forthcoming systematic reviews. Searches were built around the following four concepts: primary teeth AND caries/carious lesion AND Minimal Intervention Dentistry AND systematic review/meta-analysis. Searches were restricted to English language, systematic reviews with/without meta-analyses published between January 2000 and August 2020. Two reviewers independently screened all titles and abstracts. Interventions included involved no dentine carious tissue removal (fissure sealants, resin infiltration, topical application of 38% Silver Diamine Fluoride, and Hall Technique), non-restorative caries control, and selective removal of carious tissue involving both stepwise excavation and atraumatic restorative treatment. Systematic reviews were selected, data extracted, and risk of bias assessed using ROBIS by two independent reviewers. Studies overlap was calculated using corrected covered area.

RESULTS

Eighteen systematic reviews were included in total; 8 assessed the caries arresting effects of 38% Silver Demine Fluoride (SDF), 1 on the Hall Technique (HT), 1 on selective removal of carious tissue, and eight investigated interventions using atraumatic restorative treatment (ART). Included systematic reviews were published between 2006 and 2020, covering a defined time frame of included randomised controlled trials ranging from 1969 to 2018. Systematic reviews assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded due to pooled data reporting on caries arrest in both enamel and outer third of dentine with the majority of these carious lesions being limited to enamel. Therefore, fissure sealants and resin infiltration are not recommended for the management of dentinal caries lesions in primary teeth. Topical application of 38% SDF showed a significant caries arrest effect in primary teeth (p < 0.05), and its success rate in arresting dental caries increased when it was applied twice (range between 53 and 91%) rather than once a year (range between 31 and 79%). Data on HT were limited and revealed that preformed metal crowns placed using the HT were likely to reduce discomfort at time of treatment, the risk of major failure (pulp treatment or extraction needed) and pain compared to conventional restorations. Selective removal of carious tissue particularly in deep carious lesions has significantly reduced the risk of pulp exposure (77% and 69% risk reduction with one-step selective caries removal and stepwise excavation, respectively). ART showed higher success rate when placed in single surface compared to multi-surface cavities (86% and 48.7-88%, respectively, over 3 years follow-up).

CONCLUSION

Minimal Intervention Dentistry techniques, namely 38% SDF, HT, selective removal of carious tissue, and ART for single surface cavity, appear to be effective in arresting the progress of dentinal caries in primary teeth when compared to no treatment, or conventional restorations. There is clear need to increase the emphasis on considering these techniques for managing carious primary teeth as a mainstream option rather than a compromise option in circumstances where the conventional approach is not possible due to cooperation or cost.

Meta-Analysis of In-Vitro Bonding of Glass-Ionomer Restorative Materials to Primary Teeth

Restoration of primary teeth is among the main clinical applications of glass-ionomer cements (GIC). The aim of the study was to review and summarize existing evidence of in vitro bond strength of glass-ionomer (GI) restoratives to enamel and dentin of primary teeth. A literature search was performed in PubMed/Medline, Scopus, Web of Science, Cochrane, and Google Scholar databases to identify studies published until April 2021. The search strategy was: (“glass”) and (“ionomer”) and (“primary” or “deciduous”) and (“bond” or “tensile” or “shear”). Two researchers independently retrieved articles that reported on the bond strength of GIC to primary dentin and/or enamel. The meta-analysis was performed to compare the bond strength values of conventional (C) GIC and resin-modified (RM) GIC to different substrates. From 831 potentially eligible articles, 30 were selected for the full-text examination, and 7 were included in the analysis. Studies were rated at high (3), medium (3), and low (1) risk of bias. RM-GIC showed higher bond strength to primary enamel and dentin compared to the C-GIC. Meta-analysis of in vitro studies, evaluating bonding properties of GI restoratives to primary teeth, suggests the superior performance of RM-GIC. However, there is a lack of studies that examine the properties of novel GI formulations.

Management of dental caries lesions in Latin American and Caribbean countries

Caries management at the lesion level is dependent on the lesion activity, the presence of a cavitation (either cleanable or non-cleanable), and lesion depth as evaluated via radiographic examination. A variety of non-invasive, micro-invasive, and minimally invasive treatment (with or without restoration) options are available for primary and permanent teeth. Non-invasive strategies include oral hygiene instructions, dietary counseling, and personal as well as professional use of fluoridated products that reduce demineralization and increase re-mineralization. Micro-invasive procedures include the use of occlusal resin sealants and resin infiltrants, while minimally invasive strategies comprise those related to selective removal of caries tissues and placement of restorations. Deep caries management includes indirect pulp capping, while exposed pulp may be treated using direct pulp capping and partial or complete pulpotomy. The aim of the present study was to review available evidence on recommended preventive and restorative strategies for caries lesions in Latin American/Caribbean countries, and subsequently develop evidence-based recommendations for treatment options that take into consideration material availability, emphasize ways to adapt available treatments to the local context, and suggest ways in which dentists and health systems can adopt these treatments.

Combination of Polydopamine Coating and Plasma Pretreatment to Improve Bond Ability Between PEEK and Primary Teeth

Preformed crowns are preferred to reduce the failure risk of restoration of primary teeth, but some drawback of conventional material is still a main barrier for their clinical use. Polyether etherketone (PEEK), a tooth colored, high-performance thermoplastic polymer, has been recognized as a promising alternative to manufacture the restoration of primary teeth. However, the hydrophobic surface and low surface energy of PEEK make it hard to establish a strong and durable adhesion. In this study, we have evaluated a modification method of polydopamine (PDA) coating with plasma pretreatment for the PEEK films by physical and chemical characterization, bonding properties, and biocompatibility. The surface properties of PEEK were well-characterized by scanning electron microscope (SEM) and X-ray photoelectron spectroscopy (XPS). The adhesive strength of the PEEK films was greatly improved without significant reduction of the proliferation rate of human gingival fibroblast cells in MTT and Live/Dead assays. Therefore, PDA coating with plasma pretreatment may give a new solution for effective clinical application of PEEK in primary performed crowns.