Treating pit-and-fissure caries: a systematic review and network meta-analysis

Evaluation of direct restorations for pit-and-fissure caries using stamp combined with single-shade composite resin technique: A 12-month follow-up in vivo study

OBJECTIVES

To evaluate the clinical performance of direct restorations for pit-and-fissure caries in molars using stamp combined with single-shade composite resin (S/SCR) technique, and assess the effect of the number of stamp pressing on the trueness of S/SCR technique.

METHODS

Twenty molars of fifteen patients with pit-and-fissure caries but with an intact or micro-cavitated occlusal morphology were restored using S/SCR technique and were randomly divided into single pressing group (n = 10) and double pressing group (n = 10). Intraoral scans were obtained before treatment (scan 1), after filling (scan 2) and after polishing (scan 3). Deviation distribution maps of pairwise fitting were created including comparison 1 (scan1/scan 2), comparison 2 (scan1/scan 3), and comparison 3 (scan2/scan 3) using Geomagic Control X software. Root mean square (RMS) values were calculated to evaluate the trueness of restorations. Clinical performances including esthetic, functional, and biological properties of all restorations were evaluated according to FDI criteria after a 12-month follow-up. Analysis of variance, independent-samples T test and Wilcoxon rank-sum test were used for statistical analysis (α=0.05).

RESULTS

RMS values for comparison 1, comparison 2, and comparison 3 were 0.1243 ± 0.0151, 0.0966 ± 0.0136, and 0.0605 ± 0.0137 mm in single pressing group, while 0.0831 ± 0.0140, 0.0741 ± 0.0107, and 0.0475 ± 0.0099 mm in double pressing group, respectively. RMS value of single pressing group was higher than that of double pressing group in the same comparison (p ≤ 0.001). No statistically significant differences were observed between the two groups regarding esthetic, functional and biological properties (p > 0.05). For all properties, all restorations scored within 3, with over 80% scoring 1.

CONCLUSION

S/SCR technique presents satisfying clinical performances for pit-and-fissure caries in molars after a 12-month follow-up. Besides, double pressing can improve the trueness of restorations compared to single pressing.

CLINICAL SIGNIFICANCE

S/SCR technique is efficient in direct composite resin restoration for pit-and-fissure caries, with satisfying esthetic, functional and biological properties after a 12-month follow-up. Significantly, double pressing improves the trueness of S/SCR technique, reducing the need for occlusion adjustment.

ARE PIT AND FISSURE SEALANTS EFFECTIVE IN PREVENTING AND ARRESTING OCCLUSAL CARIES IN PRIMARY AND PERMANENT TEETH? AN OVERVIEW OF SYSTEMATIC REVIEWS

OBJECTIVES

To compile the evidence from systematic reviews (SRs) about the use of sealants for preventing and arresting pit and fissure occlusal caries in primary and permanent teeth.

MATERIALS AND METHODS

A search was performed in six databases and gray literature up to May 2023. Systematic reviews (SRs) that included randomized trials (RCTs) and nonrandomized clinical trials (n-RCTs) aiming to answer the PICO-based focused question "are pit and fissure sealants (I) more effective than other interventions, control or no treatment (C) in preventing and arresting occlusal caries (O) in primary and permanent teeth (P)?", were included. The methodological quality was assessed using the AMSTAR-2. The overlap between reviews was calculated (corrected covered, CCA).

RESULTS

Among the 25 included SRs, 18 underwent meta-analysis. Eighteen SRs considered sealing enamel caries lesions, one considered sealing dentine caries, and six considered both. Seventeen SRs were devoted to preventive sealing (RCT only, n = 12; RCT and n-RCT, n = 5), while eight were devoted to prevention and arrest of dental caries (RCT only, n = 5; RCT and n-RCT, n = 3). Nine SRs showed positive results for the primary dentition, and the most frequent periods of follow-up were at least 6 (n = 5) and 12 months (n = 4). According to our meta-analysis, a significant association between resin-based sealants (RBS) and dental caries prevention was detected at 6 months (n = 1) and over longer follow-up periods (n = 4), and the DMFT and dmft indices decreased (n = 2). RBS was better than fluoride varnish at preventing dentine caries (n = 1). A lower caries incidence rate was observed in the resin-modified glass ionomer group at 6 months (n = 1). Overall, the sealants were superior (n = 11), similar (n = 21), or inferior (n = 1) to the other treatments. The AMSTAR-2 scores for studies on preventive sealing were critically low (n = 8), low (n = 6), moderate (n = 1) and high (n = 2) for studies on preventive sealing and critically low (n = 5), low (n = 2) and high (n = 1) for studies on the prevention and arrest of caries lesions. The overlap was low (CCA = 3%).

CONCLUSION

This overview suggests that pit and fissure sealants are not inferior to other interventions in preventing and arresting dental caries lesions in primary and permanent teeth.

Detection of pit and fissure sealant microleakage using quantitative light-induced fluorescence technology: an in vitro study

This in vitro study aimed to evaluate the feasibility of quantitative light-induced fluorescence (QLF) technology for detecting the presence and severity of microleakage of pit and fissure sealants. The areas of interest (AOIs) were 160 pits and fissures of 40 extracted permanent teeth. Fluorescent images were acquired using a QLF device, and the maximum fluorescence loss ΔFmax of each AOI was analyzed. After staining and cross-sectioning of the teeth, histological dye penetration was scored on a scale of 0 to 3. The relationship between ΔFmax and microleakage depth was analyzed, and the areas under the curve (AUCs) were calculated. The │ΔFmax│ increased as microleakage depth increased. The ΔFmax values of microleakage areas showed a strong significant correlation with the histological scores of dye penetration (r = - 0.72, P = 0.001). AUC analysis showed a high diagnostic accuracy for microleakage depth (AUC = 0.83-0.91). The highest AUC of 0.91 was found when differentiating the outer half microleakage of the sealant (histological score 0 vs. 1-3). QLF technology is effective in assessing the presence and severity of microleakage, suggesting its potential for noninvasive detection and monitoring of sealant microleakage in clinical settings.

Comparing the effectiveness of caries arrest by micro-operative treatment to operative treatment: A 2-year randomized controlled clinical trial

OBJECTIVES

To compare the effectiveness of caries arrest by micro-operative treatment (sealing) to operative treatment (flowable resin composite restoration) through a 2-year randomized controlled clinical trial.

MATERIALS AND METHODS

A prospective randomized controlled trial was conducted among 7-9-year-old children. At baseline, 630 subjects were screened and 92 children who had at least one carious lesion classified as ICDAS 3 on the pit and fissure of first permanent molar were included. Then they were randomly assigned to the sealant group (73 lesions) and the flowable resin composite group (76 lesions) to receive the corresponding intervention. Lesions status in each group was evaluated every 6 months up to 24 months. Clinical progression of dental caries and materials retention were the outcomes used for group comparisons at p-value < 0.05.

RESULTS

After 24 months, three lesions (4.1%) in the sealant group clinically progressed to dentin caries. No lesion in the flowable composite group was observed a progression. The results of Life-table survival analysis show that the cumulative caries arrest rate had no statistically significant difference between the two groups (p = 0.075). However, the cumulative retention rate was 57.5% in the sealant group and 92.1% in the flowable composite group, with significant differences (p < 0.001). The multilevel mixed model showed the sealant had higher risk of retention failure than the flowable composite (OR = 8.66, p < 0.001), while tooth position did not influence material retention (p = 0.083). In addition, the results of Fisher Exact test show that dentin lesions had more retention failure than enamel lesions in the sealant group (p = 0.026).

CONCLUSION

Although sealing microcavitated carious lesions of the first permanent molar achieved lower retention rate than resin composite restoration, both sealing and restoration effectively arrested caries progression for two years.

CLINICAL RELEVANCE

To preserving dental structure and delaying or eliminating the need for operative procedures, microcavitated carious lesion can be arrested by sealing.

TRIAL REGISTRATION

Registered at http://www.chictr.org.cn ; Feb 15th, 2020; No. ChiCTR2000029862.

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.

Assessment of oral health status and related factors in adolescents aged 12-15 years in the Gansu Province of China: a cross-sectional survey

BACKGROUND

The national oral epidemiological survey conducted every decade has become an indispensable means of detecting changes in oral disease patterns. This study was undertaken to investigate the oral health status and related factors in 12-15-year-old students in Gansu, China.

METHODS

According to the methodology adopted by the Fourth National Oral Health Survey, a multi-stage, stratified, random sampling method was used to select 3871 adolescents aged 12-15 years from four regions of Gansu Province for oral examination and questionnaire survey. Caries experience was measured using the Decayed, Missing, and Filled Teeth (DMFT) index; and periodontal health examination included gingival bleeding, calculus, periodontal pockets and attachment loss. The questionnaire included questions regarding sociodemographic characteristics, and oral health knowledge and behaviors. SPSS20.0 software was used for statistical analysis of the survey data.

RESULTS

The mean DMFT index was 0.83 ± 1.42. The prevalence of caries experience was 38.6%, filling rate was 1.6%, and pit and fissure sealing rate was 0.5%. Logistic regression analysis showed that female sex, rural district, older age, non-only child, frequency of dental visits, and toothache experience were the risk factors for caries experience, with OR ranging between 1.280 and 3.831 (p < 0.05). Prevalence of healthy periodontium was 29.8%. Female sex, rural district, and younger age were found to be the protective factors for healthy periodontium, with OR ranging between 1.178 and 1.414 (p < 0.05).

CONCLUSIONS

Adolescents in Gansu Province had high prevalence of caries experience along with low filling rate, and low prevalence of healthy periodontium. Therefore, it is necessary to vigorously strengthen oral health education, disease prevention and control programs in the province. This would help improve the oral health-related quality of life of these individuals.

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.

FISSURE SEALANT IN A NUTSHELL. EVIDENCE-BASED META-EVALUATION OF SEALANTS' EFFECTIVENESS IN CARIES PREVENTION AND ARREST

OBJECTIVE

This meta-evaluation aimed to summarize all available evidence regarding different fissure sealants on occlusal caries prevention, arrest, retention rate, adverse effect, and cost-effectiveness; when compared with no intervention, other preventive or minimally-invasive procedures.

MATERIALS AND METHODS

The systematic reviews and meta-analyses were identified via four electronic databases and manual searching. Two independent reviewers performed study selection, data extraction, quality assessment with AMSTAR-2.

RESULTS

Among the 366 records yielded, 38 systematic reviews were identified as eligible 24 of them included meta-analyses. Moderate evidence has supported the efficacies of resin-based sealants (RBS) in occlusal caries prevention, arrest and cost-effectiveness compared to no interventions. Low to very low certainty of evidence suggested similar effectiveness of glass-ionomer cements in caries prevention with RBS and more superior performance of resin infiltration in arresting non-cavitated occlusal lesions.

CONCLUSION

This meta-evaluation supports the use of RBS on permanent molars to reduce occlusal caries occurrence, arrest lesion progression and alleviate oral health inequalities between individuals of different socioeconomic status. This meta-evaluation also advocates further research on glass-ionomer cements and resin infiltration with respect to their efficacies in caries prevention and arrest.

Fissure sealant therapy as a portable community-based care in deprived regions: Effectiveness of a clinical trial after 1 year follow-up

The aim of this study was to evaluate the effectiveness of the fissure sealant therapy in suboptimal setting (as part of a community-based program using the portable equipment and provided by dental students) on the caries status of school children. This pragmatic split-mouth randomised clinical trial was conducted in rural area of Iran. At baseline, 124 patients, including 185 paired teeth with deep pits and fissures of opposite quadrants that were either healthy or at early stages of enamel decay (International Caries Detection and Assessment System [ICDAS] 0-2), were randomly allocated to receive fissure sealant or acted as control. The incidence of new caries (ICDAS code 3-6) and the sealant's retention status after 1-year follow-up were evaluated. Using chi-square test, the relative risk (RR) and the Number Needed to Treat (NNT) to prevent new caries were calculated. After 1 year, 109 patients including 163 paired teeth were available. Sixty-seven (41.4%) and 44 (27.2%) teeth had complete and partial retained sealants respectively. The risk of caries incidence in non-sealed teeth was almost three times more than sealed teeth (RR = 2.88, 95% CI: 1.4-1.97, p = 0.002) and the NNT was 10 (95% CI: 6-26). A significant association was noted between the status of sealant retention after 1 year and the incidence of new caries (p < 0.001). Fissure sealant as part of a community-based program was effective in controlling caries incidence.

Microleakage of pit and fissure sealings placed after enamel conditioning with phosphoric acid or with self-etching primers/adhesives

Background

It is still not fully understood what pretreatment is best for achieving maximum tightness for pit and fissure sealings (PFS).

Aim

This study investigated microleakage of PFS placed after etching with phosphoric acid or after the application of self‐etching primers/adhesives (SEPA).

Design

131 third molars were assigned to ten groups. In Hel‐P, Helioseal® was applied after phosphoric acid etching. In the other groups, SEPA were used (Dyr‐AP: Adper™ Prompt™ L‐Pop™, Dyract® Seal; Bea: BeautiSealant Primer and Paste; Hel‐Exp: Experimental primer, Helioseal®; Hel‐Cl: Clearfil™ SE Bond¹, Helioseal®). Specimens were stored in distilled water at 37°C (28 days), followed by 3500 thermocycles and staining with 5% methylene blue (M) or 5% silver nitrate (S). After methylene blue staining and sectioning, microleakage was assessed light microscopically. During silver nitrate staining, specimens were dissolved by 32% HCl and remaining PFS were evaluated under a SEM.

Results

Tightness, percentage of penetrated area, and maximum dye penetration were best for Hel‐P and Hel‐Cl (p < 0.05).

Conclusions

Phosphoric acid etching of enamel and Clearfil™ SE Bond resulted in the best sealing quality. Methylene blue staining allowed the evaluation of more criteria (fissure shape, voids, sealant penetration depth) compared to silver nitrate.

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

Objectives To define an expert Delphi consensus on when to intervene in the caries process and existing carious lesions.Methods Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.Results Lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations may be placed for form, function, aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated lesions which are cleansable. Cavitated lesions which are not cleansable usually require minimally invasive management. In specific circumstances, mixed interventions may be applicable. Occlusally, cavitated lesions confined to enamel/non-cavitated lesions extending radiographically into deep dentine may be exceptions. Proximally, cavitation is hard to assess tactile-visually. Most lesions extending radiographically into the middle/inner third of dentine are assumed to be cavitated. Those restricted to the enamel are not cavitated. For lesions extending radiographically into the outer third of dentine, cavitation is unlikely. These lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds.Conclusions Comprehensive diagnosis is the basis for systematic decision-making on when to intervene in the caries process and existing lesions.

Efficacy and safety of acupuncture and moxibustion for herpes zoster: A protocol for systematic review and network meta analysis

INTRODUCTION

Herpes zoster (HZ) is currently treated primarily with antiviral drugs, yet this treatment has been debated. Acupuncture is becoming a more important treatment in this protocol. For example, pain intensity is lower among HZ patients who receive acupuncture plus moxibustion than among those who receive pharmacotherapy. There are many types of acupuncture interventions, including electroacupuncture, moxibustion, bloodletting. In this study, a network meta-analysis (NMA) is used to rank various interventions of acupuncture.

METHODS AND ANALYSIS

Electronic searches of abstracts and titles will be performed in MEDLINE, EMBASE, CENTRAL, CBM, CNKI, CQVIP, and Wanfang Data databases, from inception to December 31, 2019. Published and unpublished controlled trials with different acupuncture interventions will be selected, trials of antiviral drugs as the control group. All patients of HZ will be included, except for those diagnosed with PHN, immunocompromised patients, or those with complications. The effective therapy rate and the incidence of PHN are primary outcomes. The NMA will be analyzed with Stata 13.0 and GeMTC 0.14.3.

DISCUSSION

The NMA will be established to compare various interventions of acupuncture for the therapy of HZ, that could resolve the limitations of previous methodologies with this protocol. It will be possible to determine the best acupuncture intervention for more primary outcomes of therapy, including subgroup analysis of patients with aged ≥50 years and those of aged <50 years.

ETHICS AND DISSEMINATION

The NMA does not require ethical approval. The data analyzed is not personal. It is only systematically used to evaluate the effectiveness of acupuncture treatments. The results will be disseminated through international conference reports and peer-reviewed manuscripts.

STRENGTH AND LIMITATIONS OF THIS STUDY

A comprehensive methodology is established to rank various interventions of acupuncture by which best evidence-based intervention may be recommended for those population groups of aged ≥50 years and aged <50 years.

PROSPERO REGISTRATION NUMBER

CRD42019118369.

How to Intervene in the Caries Process in Children: A Joint ORCA and EFCD Expert Delphi Consensus Statement

This paper provides recommendations for dentists for the treatment of dental caries in children, with an emphasis on early childhood caries (ECC), primary teeth, and occlusal surfaces in permanent teeth. A consensus workshop followed by an e-Delphi consensus process was conducted with an expert panel nominated by the European Organization for Caries Research (ORCA) and European Federation of Conservative Dentistry (EFCD)/German Association of Conservative Dentistry (DGZ) boards. Based on 3 systematic reviews and a nonsystematic literature search, recommendations were developed. The caries decline has led to a more polarized disease distribution in children and adolescents along social gradients which should be taken into account when managing the caries process at all levels, such as the individual, the group, or a population. The control or reduction of caries activity is the basis for successful caries management. In children, caries management requires adequate daily oral hygiene and fluoride application via toothpaste, ensured by caregivers, and especially for ECC prevention an emphasis on sugar intake reduction is needed. These noninvasive interventions are also suitable to arrest or control initial or even cavitated dentine caries lesions in the absence of irreversible pulpitis. Fluoride varnish or silver diammine fluoride can be added as supplementary agents. In pits and fissures, composite resin materials can be used as preventive sealants and for defect-oriented minimally invasive restorations. In primary molars, preformed metal crowns are more successful than multisurface fillings, especially in caries-active patients. With persisting high caries activity, multiple lesions, and limited cooperation, caries control should consist of robust measures with high success rates, even including extraction in selected cases. This applies especially to treatments performed under general anesthesia.

Effectiveness of Pit and Fissure Sealants for Preventing and Arresting Occlusal Caries in Primary Molars: A Systematic Review and Meta-Analysis

OBJECTIVE

The use of pit and fissure sealants have been well supported in permanent teeth, but no concrete evidence is available to support this procedure in primary molars. This review aims to systematically assess randomized controlled trials and summarize the evidence on the effectiveness of different sealants in prevention and arrest of the pit and fissure occlusal caries in primary molars of children.

MATERIALS AND METHODS

Four electronic databases were searched from inception to March 2018. Seven studies were included in the qualitative and quantitative syntheses. Two reviewers independently selected studies, extracted data, assessed risk of bias using the revised Cochrane risk of bias tool, and evaluated the certainty in the evidence adopting the Grading of Recommendations Assessment Development and Evaluation approach. Odds ratio and retention rate of different sealants were recalculated and analyzed.

RESULTS

This review identified no significant difference in the overall caries incidence and progression when evaluated over 24 months between (1) resin-based sealant (RBS) and glass ionomer sealants (GIS) or resin-modified GIS; (2) conventional and newly developed RBS; (3) autopolymerized and light-polymerized RBS; (4) RBS with topical fluoride application and topical fluoride alone; and (5) RBS with topical fluoride application and resin infiltration with topical fluoride application. The pooled estimates of the mean retention rates of RBS and GIS on primary molars over an 18-months period were 85.94% and 23.18%, respectively. The certainty in the evidence of each outcome was determined as low or very low mainly because of high risk of overall bias and imprecision.

CONCLUSION

There are currently insufficient well-controlled randomized controlled clinical trials to determine whether sealants are beneficial in preventing or arresting noncavitated occlusal caries in the primary molars.

Coronavirus disease (COVID-19): Characteristics in children and considerations for dentists providing their care

The emergence of the novel virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease (COVID-19) has led to a global pandemic and one of the most significant challenges to the healthcare profession. Dental practices are focal points for cross-infection, and care must be taken to minimise the risk of infection to, from, or between dental care professionals and patients. The COVID-19 epidemiological and clinical characteristics are still being collated but children's symptoms seem to be milder than those that adults experience. It is unknown whether certain groups, for example children with comorbidities, might be at a higher risk of more severe illness. Emerging data on disease spread in children, affected by COVID-19, have not been presented in detail. The purpose of this article was to report current data on the paediatric population affected with COVID-19 and highlight considerations for dentists providing care for children during this pandemic. All members of the dental team have a professional responsibility to keep themselves informed of current guidance and be vigilant in updating themselves as recommendations are changing so quickly.

Mineral deposition promoted by resin-based sealants with different calcium phosphate additions

The aim of this study was to evaluate the influence of different calcium phosphates (CaPs) on the physical, biological, and remineralizing properties of experimental resin-based sealants (RBSs). Triethylene-glycol dimethacrylate (90wt%) and bisphenol A-glycidyl methacrylate (10wt%) were used to produce resin-based sealants. Hydroxyapatite (SHAp), α-tricalcium phosphate (Sα-TCP) and octacalcium phosphate (SOCP) were added to the sealants in a 10wt% concentration. One group without CaPs was used as the control group (SCG). The degree of conversion (DC) was assessed with Fourier-transformed infrared spectroscopy, whereas cytotoxicity was tested with the HaCaT keratinocyte cell line. The ultimate tensile strength (UTS) was used to assess the mechanical strength of the experimental RBSs. Sealed enamel was used for colorimetric assay. Mineral deposition was assessed with Raman spectroscopy after 7, 14, and 28 days of sample immersion in artificial saliva. Scanning electron microscopy was used to analyze the surface morphology after 28 days of immersion. The addition of 10wt% of fillers significantly reduced the DC of sealants. SOCP groups showed reduced cell viability. Higher UTS was found for Sα-TCP and SHAp. The color analysis showed that SGC and demineralized teeth presented higher mismatches with the sound tissue. Mineral deposition was observed for SHAp and Sα-TCP after 7 days, with increased phosphate content and mineral deposits for SHAp after 28 days. RBS with the addition of 10% HAp promoted increased mineralization in vitro after 28 days, and did not affect cell viability, DC, mechanical properties, or RBS color in the enamel.

Nonrestorative Management of Cavitated and Noncavitated Caries Lesions

The objective of this article is to review evidence-based strategies available for the nonrestorative management of caries lesions, both cavitated and noncavitated. The goal is to help clinicians make appropriate decisions regarding nonrestorative management of caries lesions. In addition, in the decision-making process, clinicians must consider thresholds for restorative and nonrestorative care and strategies for nonrestorative management that are supported by best available evidence. It is important that this information be considered taking into account a provider's clinical expertise and a patient's treatment needs and preferences, in order to maintain health and preserve tooth structure.

When to intervene in the caries process? An expert Delphi consensus statement

OBJECTIVES

To define an expert Delphi consensus on when to intervene in the caries process and on existing carious lesions using non- or micro-invasive, invasive/restorative or mixed interventions.

METHODS

Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.

RESULTS

Carious lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations will be placed for reasons of form, function and aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated carious lesions which are cleansable. Cavitated lesions which are not cleansable usually require invasive/restorative management, to restore form, function and aesthetics. In specific circumstances, mixed interventions may be applicable. On occlusal surfaces, cavitated lesions confined to enamel and non-cavitated lesions radiographically extending deep into dentine (middle or inner dentine third, D2/3) may be exceptions to that rule. On proximal surfaces, cavitation is hard to assess visually or by using tactile methods. Hence, radiographic lesion depth is used to determine the likelihood of cavitation. Most lesions radiographically extending into the middle or inner third of the dentine (D2/3) can be assumed to be cavitated, while those restricted to the enamel (E1/2) are not cavitated. For lesions radiographically extending into the outer third of the dentine (D1), cavitation is unlikely, and these lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds.

CONCLUSIONS

Comprehensive diagnostics are the basis for systematic decision-making on when to intervene in the caries process and on existing carious lesions.

CLINICAL RELEVANCE

Carious lesion activity, cavitation and cleansability determine intervention thresholds. Invasive treatments should be applied restrictively and with these factors in mind.

"Setting the scene in early childhood" - an MID approach for life

This article presents a discussion paper for both consideration and implementation of Minimal Intervention Dentistry (MID) principles by the general dental practitioner. It argues that if these concepts can be adopted in early childhood by both the community and the profession, "Teeth for Life" can become a reality for all. Oral Health promoting behaviours can be nurtured and supported from infancy and developed into everyday living practice for a lifetime thereby maintaining an optimal quality of life. MID techniques have become more refined and supported by scientific research in the recent times and should be considered an essential clinical guideline for the future disease management.

Boron Nitride Nanotubes as Filler for Resin-Based Dental Sealants

The aim of this study was to evaluate the influence of boron-nitride nanotubes (BNNTs) on the properties of resin-based light-curing dental sealants (RBSs) when incorporated at different concentration. RBSs were formulated using methacrylate monomers (90 wt.% TEGDMA, 10 wt.% Bis-GMA). BNNTs were added to the resin blend at 0.1 wt.% and 0.2 wt.%. A Control group without filler was also designed. Degree of conversion, ultimate tensile strength, contact angle, surface free energy, surface roughness and color of the RBSs were evaluated for the tested materials. Their cytotoxicity and mineral deposition ability (Bioactivity) were also assessed. A suitable degree of conversion, no effect in mechanical properties and no cytotoxic effect was observed for the experimental materials. Moreover, the surface free energy and the surface roughness decreased with the addition of BNNTs. While the color analysis showed no difference between specimens containing BNNTs and the control group. Mineral deposition occurred in all specimens containing BNNTs after 7d. In conclusion, the incorporation of BNNTs may provide bioactivity to resin-based dental sealants and reduce their surface free energy.

Tailored Dentistry: From "One Size Fits All" to Precision Dental Medicine?

Over the past 30 years and fueled by both a rapidly evolving understanding of dental diseases and technological advances in diagnostics and therapy, dentistry has been changing dramatically. Managing dental caries and carious lesions had, for nearly a century, encompassed only a small number of basic concepts that were applied to virtually all patients and lesions, namely, invasive removal of any carious tissue regardless of its activity or depth and its replacement with restorative materials (amalgams or crowns for most of the past) or tooth removal and prosthetic replacement. Grounded in a deeper understanding of the disease "caries," its management-aiming to control the causes of the disease, to slow down or alleviate existing disease, and, only as a last resort, to remove its symptoms using a bur or forceps-has become more complex and diverse. In parallel and at nearly unprecedented speed, our patients are changing, as mirrored by ongoing debates as to the demographic and, with it, the social future of most high-income countries. This article describes how these changes will have a profound future impact on how we practice dental medicine in the future. It will deduce, from both demographic and epidemiologic trends, why there is the need to apply not one but rather the whole range of existing evidence-based concepts in an individualized (personalized) manner, hence increasing the effectiveness and efficiency of dental management strategies, and also describe how these strategies should be tailored according not only to our patients (their age and risk profiles) but also to the specific tooth (or site or lesion).

Bioactive glass ceramic can improve the bond strength of sealant/enamel?

AIM

Evaluate the influence of enamel pre-treatment using Biosilicate, associated or not to other treatments; on the bond strength (BS) of pit-and-fissure sealant, with or without saliva contamination.

METHODS

Ninety slices (4 mm × 4 mm) were obtained from 30 bovine incisors. Each slice was embedded in acrylic resin with their buccal surface exposed and polished to obtain a flat enamel surface. Half of them were contaminated with human saliva. All specimens were randomly divided into five groups (n = 9) according to the surface pre-treatment tested: acid etching (AE); AE + Biosilicate (B); AE + B + total-etch adhesive (Ad); Biosilicate; control (no treatment). Then, a 1 mm layer of sealant (Clinpro XT Varnish, 3M ESPE) was applied; and to provide support, a composite resin (Opallis, FGM) block was built up over it. Samples were thermocycled (500 cycles/5-55 °C) and sectioned obtaining sticks (1 × 1 × 10 mm) for microtensile BS testing (0.5 mm/min). Data were analysed with two-way ANOVA, Bonferroni test, p < 0.05. Failure patterns were evaluated using a stereomicroscope.

RESULTS

There was no difference among contaminated and non-contaminated groups, and between non-contaminated groups (p > 0.05). When contaminated, AE + B + Ad Group showed the highest BS values, differing (p < 0.05) from B Group and Control; similar between them (p > 0.05). Cohesive fractures were found in AE + B + Ad Group, submitted or not to contamination.

CONCLUSIONS

Since a surface pre-treatment was used, whether Biosilicate was applied or not, the sealant/enamel BS was the same in saliva-contaminated or non-contaminated enamel.

Clinical Evaluation of Two Different Prevention Programs in Adults Depending on Their Caries Risk Profile: One-year Results

The aim of this study was to investigate the management of incipient caries lesions in adults with two preventive protocols. A total of 44 adult patients with high, moderate and low caries risk with 516 incipient caries took part in the study. These patients were assessed for caries with International Caries Detection and Assessment System (ICDAS) criteria and were then divided into three groups depending on their caries risk profile: a high-risk group (group A), a moderate-risk group (group B), and a low-risk group (group C). Participants in each group were further divided randomly into two subgroups. In subgroups A1, B1, and C1, an intensive preventive protocol was applied, while in subgroups A2, B2, and C2, the protocol consisted only of instructions in oral hygiene. The invasive-intensive protocol included the topical application of fluoride, brushing with 5000-ppm fluoride toothpaste, use of amorphous calcium phosphate-casein phosphopeptide, applications of sealants for occlusal lesions (ICDAS code 2), and minimal resin restorations for occlusal lesions (ICDAS code 3). There was no statistically significant difference in the number of lesions (baseline and after one year) in the high-risk and moderate-risk groups that received the intensive protocol (groups A1 and B1), while the control groups were statistically significant different (groups A2 and B2). In the low-risk group, there was no statistically significant difference in the number of lesions (groups C1 and C2). The two different preventive protocols in the high- and moderate-risk groups presented differences in effectiveness, while in the low-risk group, no significant difference was demonstrated.

Evidence-Based Dentistry Caries Risk Assessment and Disease Management

The objective of this article was to provide a summary of evidence-based recommendations for the assessment of caries risk and management of dental caries. The goal is to help clinicians manage the caries disease process using personalized interventions supported by the best available evidence, taking into account the clinician's expertise and the patient's needs and preferences, to maintain health and preserve tooth structure.

Nonrestorative Treatments for Caries: Systematic Review and Network Meta-analysis

The goal of nonrestorative or non- and microinvasive caries treatment (fluoride- and nonfluoride-based interventions) is to manage the caries disease process at a lesion level and minimize the loss of sound tooth structure. The purpose of this systematic review and network meta-analysis was to summarize the available evidence on nonrestorative treatments for the outcomes of 1) arrest or reversal of noncavitated and cavitated carious lesions on primary and permanent teeth and 2) adverse events. We included parallel and split-mouth randomized controlled trials where patients were followed for any length of time. Studies were identified with MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews. Pairs of reviewers independently conducted the selection of studies, data extraction, risk-of-bias assessments, and assessment of the certainty in the evidence with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Data were synthesized with a random effects model and a frequentist approach. Forty-four trials (48 reports) were eligible, which included 7,378 participants and assessed the effect of 22 interventions in arresting or reversing noncavitated or cavitated carious lesions. Four network meta-analyses suggested that sealants + 5% sodium fluoride (NaF) varnish, resin infiltration + 5% NaF varnish, and 5,000-ppm F (1.1% NaF) toothpaste or gel were the most effective for arresting or reversing noncavitated occlusal, approximal, and noncavitated and cavitated root carious lesions on primary and/or permanent teeth, respectively (low- to moderate-certainty evidence). Study-level data indicated that 5% NaF varnish was the most effective for arresting or reversing noncavitated facial/lingual carious lesions (low certainty) and that 38% silver diamine fluoride solution applied biannually was the most effective for arresting advanced cavitated carious lesions on any coronal surface (moderate to high certainty). Preventing the onset of caries is the ultimate goal of a caries management plan. However, if the disease is present, there is a variety of effective interventions to treat carious lesions nonrestoratively.

Pit and Fissure Sealants-A Comprehensive Review

Even in the 21st century, dental caries is considered a global burden, severely upsetting the health and quality of life of those affected. Apart from the usage of fluoride and regular oral hygiene, one of the most important prophylactic approaches against the occurrence of caries is the sealing of pits and fissures. However, the rapid progress of new materials and applications for sealing pits and fissures also raises new questions about their correct application. Recent literature on pit and fissure sealing, caries prevention, as well as caries risk assessment for both children and adults was reviewed. This report provides a general overview of pit and fissure sealing, the materials used for sealing occlusal surfaces, as well as indications and possible side effects. The conclusions are that sealing pit and fissures of primary and permanent teeth is an effective method for preventing and arresting caries. However, regular checkups must be conducted to avoid advanced tooth decay attributable to leakages in the sealing.

To fill or not to fill: a qualitative cross-country study on dentists' decisions in managing non-cavitated proximal caries lesions

Background

This study aimed to identify barriers and enablers for dentists managing non-cavitated proximal caries lesions using non- or micro-invasive (NI/MI) approaches rather than invasive and restorative methods in New Zealand, Germany and the USA.

Methods

Semi-structured interviews were conducted, focusing on non-cavitated proximal caries lesions (radiographically confined to enamel or the outer dentine). Twelve dentists from New Zealand, 12 from Germany and 20 from the state of Michigan (USA) were interviewed. Convenience and snowball sampling were used for participant recruitment. A diverse sample of dentists was recruited. Interviews were conducted by telephone, using an interview schedule based on the Theoretical Domains Framework (TDF).

Results

The following barriers to managing lesions non- or micro-invasively were identified: patients’ lacking adherence to oral hygiene instructions or high-caries risk, financial pressures and a lack of reimbursement for NI/MI, unsupportive colleagues and practice leaders, not undertaking professional development and basing treatment on what had been learned during training, and a sense of anticipated regret (anxiety about not restoring a proximal lesion in its early stages before it progressed). The following enablers were identified: the professional belief that remineralisation can occur in early non-cavitated proximal lesions and that these lesions can be arrested, the understanding that placing restorations weakens the tooth and inflicts a cycle of re-restoration, having up-to-date information and supportive colleagues and work environments, working as part of a team of competent and skilled dental practitioners who perform NI/MI (such as cleaning or scaling), having the necessary resources, undertaking ongoing professional development and continued education, maintaining membership of professional groups and a sense of professional and personal satisfaction from working in the patient’s best interest. Financial aspects were more commonly mentioned by the German and American participants, while continuing education was more of a focus for the New Zealand participants.

Conclusions

Decisions on managing non-cavitated proximal lesions were influenced by numerous factors, some of which could be targeted by interventions for implementing evidence-based management strategies in practice.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0744-7) contains supplementary material, which is available to authorized users.

Preventive and Therapeutic Proximal Sealing: A 3.5-Year Randomized Controlled Clinical Trial Follow-Up

OBJECTIVE

The aim of this split-mouth, randomized controlled clinical trial was to evaluate the efficacy of proximal sealing for avoiding the development of new caries lesions or arresting incipient caries lesions on the mesial surface of first permanent molars (6m) abutting lesions on the distal surface of second primary molars (05d) in children at high caries risk.

METHODS

A total of 61 children 8-10 years old were selected based on the caries status of the proximal sites of 05d and 6m. Children with caries on 05d and caries-free 6m were placed in the preventive sealing group and children with caries on both 05d and 6m in the therapeutic group. The children in each group had one 6m surface pair and in each pair one 6m surface was randomly allocated to receive a preventive or therapeutic sealing. Using a split-mouth design, the other 6m surface in the pair served as control.

RESULTS

After 3.5 years, standardized follow-up radiographs were obtained for the 45 children who remained. In the preventive sealing group, 4 out of 30 (13.3%) sealed and 16 out of 30 (53.3%) unsealed sound 6m surfaces had developed new caries lesions (p = 0.004, McNemar test). In the therapeutic sealing group, the progression of the carious lesions on 6m was observed in 3 out of 15 sealed (20.0%) and 8 out of 15 (53.3%) unsealed caries control surfaces (p = 0.06).

CONCLUSIONS

Preventive sealing on sound 6m surfaces abutting 05d lesions in children at high caries risk efficaciously prevents the development of caries lesions. Therapeutically sealing active non-cavitated caries lesions reduces the progression.

Resin infiltration of deproteinised natural occlusal subsurface lesions improves initial quality of fissure sealing

The aim of this ex vivo study was to evaluate the infiltration capability and rate of microleakage of a low-viscous resin infiltrant combined with a flowable composite resin (RI/CR) when used with deproteinised and etched occlusal subsurface lesions (International Caries Detection and Assessment System code 2). This combined treatment procedure was compared with the exclusive use of flowable composite resin (CR) for fissure sealing. Twenty premolars and 20 molars revealing non-cavitated occlusal carious lesions were randomly divided into two groups and were meticulously cleaned and deproteinised using NaOCl (2%). After etching with HCl (15%), 10 premolar and 10 molar lesions were infiltrated (Icon/DMG; rhodamine B isothiocyanate (RITC)-labelled) followed by fissure sealing (G-ænial Flo/GC; experimental group, RI/CR). In the control group (CR), the carious fissures were only sealed. Specimens were cut perpendicular to the occlusal surface and through the area of the highest demineralisation (DIAGNOdent pen, KaVo). Using confocal laser-scanning microscopy, the specimens were assessed with regard to the percentage of caries infiltration, marginal adaption and internal integrity. Within the CR group, the carious lesions were not infiltrated. Both premolar (57.9%±23.1%) and molar lesions (35.3%±22.1%) of the RI/CR group were uniformly infiltrated to a substantial extent, albeit with significant differences (P=0.034). Moreover, microleakage (n=1) and the occurrence of voids (n=2) were reduced in the RI/CR group compared with the CR group (5 and 17 specimens, respectively). The RI/CR approach increases the initial quality of fissure sealing and is recommended for the clinical control of occlusal caries.

A randomized clinical trial on the sealing of occlusal carious lesions: 3-4-year results

This randomized clinical trial aimed to assess the efficacy of sealing occlusal carious lesions in permanent teeth. The sample consisted of 54 occlusal carious lesions in permanent molars and premolars of 49 patients aged 8-43 years (median: 19 years). The inclusion criteria comprised the presence of a cavity with no access allowing biofilm control. The maximum depth of the lesion was the middle third of the dentin thickness, as assessed by bitewing radiography. The teeth were randomly assigned to sealant treatment (n = 28) or restorative treatment (n = 26). Clinical and radiographic examinations were performed after 1 year and after 3-4 years. The outcomes depended on the clinical performance of the sealant/restoration and the control of caries progression observed radiographically. Survival analysis was performed to assess success rates. Over the 3-4 years of monitoring, 2 sealants were totally lost, 1 needed repair, and 1 showed caries progression, totaling 4 failures in the sealant group. In the restoration group, 1 failure was observed (in need of repair). The success rates were 76% and 94% in the sealant and the restoration groups, respectively (p > 0.05). The sealing of occlusal carious lesions in permanent teeth succeeded in controlling caries over a 3-4-year period. However, sealed carious lesions require patient compliance in attending regular follow-ups to control the occurrence of clinical failures of the sealants.

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.

Effect of Industry Sponsorship on Dental Restorative Trials

Industry sponsorship was found to potentially introduce bias into clinical trials. We assessed the effects of industry sponsorship on the design, comparator choice, and findings of randomized controlled trials on dental restorative materials. A systematic review was performed via MEDLINE, CENTRAL, and EMBASE. Randomized trials on dental restorative and adhesive materials published 2005 to 2015 were included. The design of sponsored and nonsponsored trials was compared statistically (risk of bias, treatment indication, setting, transferability, sample size). Comparator choice and network geometry of sponsored and nonsponsored trials were assessed via network analysis. Material performance rankings in different trial types were estimated via Bayesian network meta-analysis. Overall, 114 studies were included (15,321 restorations in 5,232 patients). We found 21 and 41 (18% and 36%) trials being clearly or possibly industry sponsored, respectively. Trial design of sponsored and nonsponsored trials did not significantly differ for most assessed items. Sponsored trials evaluated restorations of load-bearing cavities significantly more often than nonsponsored trials, had longer follow-up periods, and showed significantly increased risk of detection bias. Regardless of sponsorship status, comparisons were mainly performed within material classes. The proportion of trials comparing against gold standard restorative or adhesive materials did not differ between trial types. If ranked for performance according to the need to re-treat (best: least re-treatments), most material combinations were ranked similarly in sponsored and nonsponsored trials. The effect of industry sponsorship on dental restorative trials seems limited.

Effect of a chlorhexidine/thymol and a fluoride varnish on caries development in erupting permanent molars: a comparative study

AIM

To compare the caries preventive effect of a chlorhexidine/thymol-containing antibacterial varnish with a fluoride varnish when topically applied during the eruption of permanent molars.

METHODS

The study group consisted of 189 patients, 5-14 years of age, with one 1st or 2nd permanent molar in the process of eruption. After stratification for type of molar and stage of eruption, the patients were randomised to either quarterly topical applications with an antibacterial varnish (Cervitec(®) Plus; CV group) or biannual applications with a fluoride varnish plus biannual treatments with placebo varnish (Fluor Protector; FV group). The duration of the study was 2 years. The primary endpoint was caries incidence (initial and cavitated) in the erupting molars and the secondary outcome was salivary mutans streptococci (MS) counts.

RESULTS

The groups were balanced with respect to socio-economy, oral hygiene, dietary habits and caries experience at baseline. The dropout rate was 11.6 %. The caries incidence was low (< 10 %) in both groups and there was no significant difference between the CV and FV groups with respect to occlusal caries development in the erupting molars (relative risk 1.08, 95 % CI 0.94-1.25). Significantly lower levels of salivary MS were disclosed in the CV group at the end of the study (p < 0.05).

CONCLUSIONS

No difference in occlusal caries development in young permanent molars was displayed after topical applications of either a chlorhexidine/thymol varnish or a fluoride varnish during tooth eruption.