Don't Know, Can't Do, Won't Change: Barriers to Moving Knowledge to Action in Managing the Carious Lesion

The professional perception of the International Caries Classification and Management System (ICCMS): a pragmatic randomised clinical trial

Introduction The International Caries Classification and Management System (ICCMS) was developed to standardise caries diagnosis, risk assessment and treatment decisions based on overall evidence. To evaluate its criteria in practice, a clinical trial assessed professionals' perceptions of two caries management systems.Methods A perception questionnaire was administered to two groups: one using ICCMS criteria and the other based on professional experience criteria (non-ICCMS group). The online questionnaire included quantitative scale questions to measure effort and satisfaction and two open-ended questions to collect the positive and negative perceptions of dentists by using either criteria system. The questionnaires were administered six months after the study's implementation.Results Both groups showed high levels of effort and satisfaction. Professionals using ICCMS reported more positive perceptions by citing improved diagnosis (71.4%) and standardised patient care (43%). However, they also noted negative aspects, such as increased number of questionnaires and records (58%), longer clinical sessions (43%) and higher rates of patient absenteeism (29%).Conclusion Professionals who used the ICCMS had a positive outlook on the system, with benefits seen in diagnosis and patient monitoring. However, there is room for improvement in terms of automation and simplification to enhance the professional use of the system in the clinical setting.

How different attributes are weighted in professionals' decision-making in Pediatric Dentistry-a protocol for guiding discrete choice experiment focused on shortening the evidence-based practice implementation for dental care

BACKGROUND

Important evidence has been constantly produced and needs to be converted into practice. Professional consumption of such evidence may be a barrier to its implementation. Then, effective implementation of evidence-based interventions in clinical practice leans on the understanding of how professionals value attributes when choosing between options for dental care, permitting to guide this implementation process by maximizing strengthens and minimizing barriers related to that.

METHODS

This is part of a broader project investigating the potential of incorporating scientific evidence into clinical practice and public policy recommendations and guidelines, identifying strengths and barriers in such an implementation process. The present research protocol comprises a Discrete Choice Experiment (DCE) from the Brazilian oral health professionals' perspective, aiming to assess how different factors are associated with professional decision-making in dental care, including the role of scientific evidence. Different choice sets will be developed, either focusing on understanding the role of scientific evidence in the professional decision-making process or on understanding specific attributes associated with different interventions recently tested in randomized clinical trials and available as newly produced scientific evidence to be used in clinical practice.

DISCUSSION

Translating research into practice usually requires time and effort. Shortening this process may be useful for faster incorporation into clinical practice and beneficial to the population. Understanding the context and professionals' decision-making preferences is crucial to designing more effective implementation and/or educational initiatives. Ultimately, we expect to design an efficient implementation strategy that overcomes threats and potential opportunities identified during the DCEs, creating a customized structure for dental professionals.

TRIAL REGISTRATION

https://osf.io/bhncv .

Core Cariology Curriculum Framework in Spanish for Latin American dental schools: development and consensus

The aim of this study was to develop and achieve consensus on a cariology teaching framework for dental schools in Latin American Spanish-speaking countries. The Delphi process, with a ≥8 0% pre-defined participants' agreement, included three phases and a Coordinating Group. During the Preparation phase three panels of experts were selected and invited to participate: a) Regional academic/professional Dental Associations (Associations-Panel): n = 12; b) Regional Dental Schools (Dental-Schools-Panel): existing dental schools (n = 263) from the 19 Spanish-speaking regional countries; c) International academic/professional associations Peer Experts (Peer-Panel): n = 4. Based on consensus documents from Europe, Colombia, the Caribbean, USA, Chile and Spain, and updated scientific evidence, the Coordinating Group developed a baseline framework proposal of domains, main competencies (MC) and specific competencies (SC). The Consultation-Agreement and Consensus phases included three rounds of questionnaires with a step-wise sharing of the MC updated version of the consensus framework with the Dental-Schools-Panel and including SC with the Associations-Panel. Diverse communication strategies were used ( e.g ., independent google-form questionnaires and workshops). Consensus was reached after an on-site Associations-Panel workshop and secret voting, followed by an online meeting with the Peers-Panel. A total of 127 academic/professional institutions participated (Associations-Panel: 11, 91.6%; Dental-Schools-Panel: 112, 42.6%, all countries; Peers-Panel: 4, 100%). The baseline Cariology teaching framework of 5 domains, 10 MC and 92 SC underwent modifications after agreements for a final consensus framework consisting of 5 domains, 10 MC and 85 SC. A Core Cariology curriculum framework in Spanish for Latin American Dental Schools was successfully developed and agreed upon with regional dental academic and professional institutions.

'You just don't have the time to keep bringing them back, bringing them back': the experience of primary care dental professionals in England when treating young children with carious teeth

Introduction Caries in the primary dentition affects around one-quarter of children in England. There is uncertainty and varying practice regarding the management of these children within NHS primary dental care. Silver diamine fluoride (SDF) is an approach that is not well-adopted nationally. This study aims to explore the factors affecting treatment choices for caries management in young children within primary dental care, including the use of SDF.Methods Semi-structured interviews were carried out via video conferencing with general dental practitioners and therapists working in NHS primary care. The topic guide covered factors which influence the management of caries in primary teeth, with SDF-specific questions. These were transcribed verbatim and analysed using thematic analysis.Results A total of 13 interviews were conducted with dental professionals working across Yorkshire and the East Midlands. Decision-making for caries management was dependent on inter-related factors, which also influenced SDF use. Treatment decisions were taken on a case-by-case basis, but were influenced by the child, their parents, the dental professional and service factors, along with the clinical technique.Conclusion Many individual- and system-level factors influence treatment decisions for early childhood caries. However, issues relating to remuneration and governance appear to be specific barriers to adoption of SDF in primary dental care.

Hall technique versus conventional preformed metal crowns: can paediatric dentists tell the difference on radiographs?

PURPOSE

Hall technique (HT) preformed metal crowns (PMCs) are allegedly oversized compared to conventional (C) PMCs. To investigate paediatric dentists' (PDs) perception of HT-PMCs and perception/ability to identify HT or C-PMCs on bitewings radiographs.

METHODS

An online cross-sectional questionnaire including ten bitewings (five of each of HT/CPMCs) was sent to PDs across the globe. A PMC type score (from '10') was calculated. T test, Pearson's and Fischer's Chi-square, and Odd Ratios (OR) (p < 0.05).

RESULTS

A total of 476 PDs from around the world responded. Most (97%) used PMCs in their practice. Most (98.7%) knew of, and 79% used HT-PMCs. A clear opinion shift, towards supporting HT, over time was noted (OR 11.154 [95% confidence interval (CI) 6.006-20.715]. A majority (67%) thought that HT/C-PMCs were similar radiographically. Only five PMCs were identified correctly [mean score 4.9 (± 1.73)]. A minority who thought that HT/C-PMCs were dissimilar scored higher than those who thought they were similar (5.31 ± 1.22; 4.68 ± 1.9, respectively, p < 0.00001). Nobody identified all ten PMCs. HT-PMCs were 4.63 times more identifiable than C-PMCs [(OR 24.857 CI 15.059-41.028) and (OR 5.361 CI 3.089-9.304)] for HT-PMCs and CP-MCs, respectively (p < 0.0001).

CONCLUSIONS

PDs identified the PMC type in half of the bitewings. They perceived no clear radiographic difference between HT-PMCs and C-PMCs, but their chance of recognizing HT-PMCs was five times higher than C-PMCs. HT-PMC support was high.

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.

How do dental practitioners, educators and students diagnose and manage caries risk and caries lesions? A COM-B analysis

OBJECTIVE

The International Caries Classification and Management System (ICCMS™), a comprehensive, evidence-informed, best clinical practice system, comprises a 4D cycle: 1D-Determine risk; 2D-Detect and assess lesions; 3D-Decide on a personalized care plan; and 4D-Do preventive and tooth-preserving care. The aim of this study was to establish how Colombian dental practitioners, educators and students diagnose and manage caries risk and caries lesions using the COM-B model and the ICCMS™ system.

METHODS

A total of 1094 participants (practitioners: n = 277; educators: n = 212; students: n = 605) completed a previously validated 79-item questionnaire which explores, based on the COM-B model, the practitioners' self-reported caries diagnosis and management behaviours. Descriptive statistics, Welch's ANOVAs and multiple linear regressions were computed.

RESULTS

All groups generally performed the behaviours within the 4-D categories 'Most of the time' to 'Always' (students: 4.06 ± 0.95; educators: 3.94 ± 0.98; practitioners: 3.86 ± 1.01). The most frequently performed diagnosis behaviours (1D/2D) were for practitioners assessing initial/moderate lesions (4.09 ± 1.01) and for educators and students cleaning teeth before lesion assessment (4.41 ± 0.80 and 4.38 ± 0.77 respectively). The least frequently performed decision/management (3D/4D) behaviour was non-operative care for moderate-caries lesions (when applicable) (practitioners: 2.64 ± 1.23; educators: 2.68 ± 1.17; students: 3.22 ± 1.41). Opportunity (Resources and Relevance) was the best COM-B predictor for diagnostic behaviours, whereas capability and opportunity (Relevance) were the strongest predictors for management behaviours.

CONCLUSION

Colombian practitioners, educators and students diagnose and manage caries risk and caries lesions implementing best practice with a high to very high frequency.

Evidence-based fact checking for selective procedures in restorative dentistry

OBJECTIVES

Similar to other dental specialties, there are many clinical procedures in restorative dentistry that may or may not be supported by good evidence. Thus, the effectiveness of these procedures is uncertain. The aim of this paper is to reduce this knowledge gap by critically inspecting selective procedures in restorative dentistry and exploring if these well-established or widely advocated treatment modalities are necessary for improving treatment outcomes based on the best available evidence.

MATERIALS AND METHODS

A MEDLINE search was conducted to identify research on selective procedures while focusing on clinical trials and systematic reviews. Due to their practical relevance in the decision-making process, cost-effectiveness analyses were also included.

RESULTS

Mixed results were identified regarding the included interventions. Some procedures had adequate evidence supporting them while others were mostly based on beliefs.

CONCLUSIONS

A critical review of the available literature indicates that some common restorative procedures lack adequate support from high-quality research evidence.

CLINICAL RELEVANCE

This paper attempts to highlight the need to critically examine the scientific validity of traditional knowledge and techniques through the context of current research evidence. This will not only help generate consensus between educators, clinicians, and researchers regarding restorative procedures but will also lead to improved patient care and outcomes.

COVID-19 as an opportunity for minimally-invasive dentistry: a national cross-sectional survey

Background

During the COVID19 pandemic, the Latvian government issued first absolute restrictions (elective treatments prohibited, only emergency care) and later relative restrictions (preference for non-aerosol-generating procedures (AGP) and emergency care) on dental care. This study aims to assess the impact of these restrictions on the decision made by Latvian dentists about caries treatment.

Methods

A Survey-based cross-sectional study was used. A minimum sample size of 174 dentists was estimated for national representativeness (N = 1524). The questionnaire was developed by experts and sent three times via email to Latvian dentists from July to September 2020 and was also delivered in printed form at two national conferences in September and October 2020. Descriptive statistics were calculated.

Results

We received 373 completed questionnaires, with a total response rate of 24.5%. Under the recommendation to reduce AGP for the treatment of uncomplicated caries, 10% of the dentists stated that they would stop attending, 54% would only attend emergencies, and 36% would attend as usual. Under prohibition, the percentages are 15%, 74%, and 11%, respectively. Regarding the type of treatment, more than 75% would opt to proceed with selective caries removal for both primary and permanent teeth and 10% for extraction.

Conclusion

Latvian dentists are willing to treat patients with caries during the pandemic and state that they prefer to use non- or minimally invasive and less aerosol-generating methods for caries treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02432-7.

Pulp Vitality and Longevity of Adhesive Restorations Are Not Affected by Selective Carious Removal: A Multicenter Clinical Trial

The aim of this multicenter randomized clinical trial was to evaluate the pulp vitality and survival rate of adhesive restorations performed on posterior deciduous teeth after non-selective (NSCR) or selective (SCR) carious tissue removal over 33 months. One hundred and seven children (average age 4-8 years, SD 1.4) with at least two active moderate cavitated lesions in dentin were included. Teeth were randomized and submitted to NSCR or SCR before composite resin restoration. Restorations were clinically and radiographically assessed at baseline, 6, 12, 18, 24, and 33 months by a blinded, trained, and calibrated operator in each center. The characteristics of the restorations were recorded according to FDI criteria and were considered as restorative failures when scores 4 or 5 were presented. Pulp vitality was measured by clinical and radiographic examinations, and those teeth that presented any signs or symptoms of irreversible pulpitis or pulp necrosis were considered as failure. Data were analyzed by a Cox regression model with shared frailty, considering two outcomes: pulp and restorative. A total of 278 restorations (137 after NSCR and 141 after SCR) were performed at baseline in four different centers and there was no loss in the follow-up period. Survival rate was 97.1 and 87.1% for pulp and for restorative outcome, respectively. The overall annual failure rate was 7%. There were no differences in the failure risk according to the treatment group, center, and all the clinical and demographic variables, regardless of outcome. Composite restorations of active moderate deep carious lesions performed on posterior primary teeth show satisfactory survival for restorative and pulp outcome after a 33-month follow-up, regardless of the technique executed for carious tissue removal.

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.

Knowledge and opinions of French dental students related to caries risk assessment and dental sealants (preventive and therapeutic)

OBJECTIVES

A national questionnaire study was performed to document knowledge and opinions of French dental students (FDSs) about minimal intervention (MI) in dentistry especially caries risk assessment (CRA) and dental sealants (DSs).

MATERIALS AND METHODS

A questionnaire was administered to the fifth-year dental FDSs (n = 1370) from the 16 French dental schools. Descriptive and statistical analyses were performed.

RESULTS

The response rate was 84.5%. A large majority of respondents (87.8%) linked MI with minimally invasive dentistry and 77.4% considered MI as a concept based on prevention. About 80% stated they use CRA in clinical practice, mostly without any specific form. If 80.4% of the respondents would base their treatment plans on CRA, only 55.1% would regularly plan preventive regimens according to individual risk level. However, while 96.6% declared they perform preventive DSs, only 44.3% considered therapeutic sealants as a routine treatment. Although 75.1% of FDSs stated that they had sufficient learning and training related to CRA, 55.9% thought that they need further education about preventive and therapeutic DSs.

CONCLUSION

Although FDSs seem to be aware of the importance of CRA and preventive strategies, this study shows the need to harmonize the teaching in cariology according to the latest European recommendations.

CLINICAL RELEVANCE

A national questionnaire study showed variability towards knowledge and opinions of FDSs related to MI in cariology. This may impact care provisions in their future professional life showing the urgent need to harmonize the teaching of MI in cariology in France.

Salivary levels of Streptococcus mutans and Lactobacilli and other salivary indices in patients wearing clear aligners versus fixed orthodontic appliances: An observational study

OBJECTIVE

This study aimed to investigate salivary levels of Streptococcus mutans (S. mutans) and Lactobacilli, and other salivary indices in subjects wearing clear aligners (CA) in comparison with multibrackets orthodontic appliances (MB).

MATERIALS AND METHODS

A sample of 80 participants (46 males and 34 females) was included in the study: 40 subjects (aged 20.4±1.7 years) were treated with CA, and 40 (aged 21.3±1.7 years) were treated with MB. Plaque index (PI), salivary flow, buffering power of saliva, and salivary levels of S. mutans and Lactobacilli were evaluated prior to start of orthodontic treatment (t0), after 3 months (t1) and 6 months (t2).

RESULTS

CA patients maintained PI at level 0 over time, while MB participants experienced a statistically significant increasing trend of PI over time. In addition, at t2, 37.5% of MB participants (15 subjects over 40) showed risky salivary levels (CFU/ml>105) of S. mutans (odds ratio = 7.40; 95% C.I. = 1.94-28.25; chi-square = 10.32; p = 0.001) as well as Lactobacilli (odds ratio = 23.40; 95% C.I. = 2.91-188.36; chi-square = 15.31; p = 0.0001).

CONCLUSIONS

Comparing all the data, subjects treated with CA achieved lower salivary microbial colonization after 6 months of treatment compared with MB. Different additional strategies for plaque control and salivary microbial colonization must be triggered considering the type of orthodontic appliance.

Use of the Hall technique by specialist paediatric dentists: a global perspective

Background The Hall technique (HT) is popular with UK paediatric dentists (PDs). Global PDs perception/use of HT is unknown.Aim To investigate global PDs opinions/use of HT.Materials and methods A cross-sectional questionnaire of 26 questions was sent to specialist PDs across the globe.Results Responses of 709 PDs from six continents were obtained. The majority (n = 654, 92.32%) had heard about HT but only 50.6% (n = 358) used it, with wide country variations. Respectively, 37.5%, 31.5% and 31% were neutral, against or supportive of HT when they initially heard about it. Only 17% of HT users said it was always the treatment of choice for non-pulpal asymptomatic carious primary molars (NPACPMs), 62% would take a pre-operative radiograph, 65% would consider using high speed drills before HT, 63% would never consider HT under general anaesthesia, 56% would use HT under N₂O sedation. Finally, in a clinical scenario of a NPACPM in a cooperative 6-year-old, 75% of PDs would choose conventional restorative methods over the HT.Conclusion The HT is recognised, but not used, by an outright majority of PDs across the globe. Identifiable barriers such as lack of training, perception as substandard dentistry and perceived lack of evidence reduced its use.

Surgical Management of Caries Lesions: Selective Removal of Carious Tissues

Traditionally, before placing a restoration, excavation of tissues affected by caries was recommended. The goal was to have all walls of the cavity on sound, hard dentin, even when at risk of pulpal exposure. Current understanding of the caries process indicates that preserving tooth structure can lead to better long-term outcomes. Selective caries excavation refers to preserving tooth structure by delineating excavation in the pulpal and axial wall according to lesion severity and depth as well as pulpal health while keeping all cavity margins on sound tooth structure. Compounding evidence indicates that when a good marginal seal is present, the lesion will arrest.

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.

The changing landscape of professional practice in podiatry, lessons to be learned from other professions about the barriers to change - a narrative review

BACKGROUND

The delivery of healthcare is changing and aligned with this, the podiatry profession continues to change with evidence informed practice and extending roles. As change is now a constant, this gives clinicians the opportunity to take ownership to drive that change forward. In some cases, practitioners and their teams have done so, where others have been reluctant to embrace change. It is not clear to what extent good practice is being shared, whether interventions to bring about change have been successful, or what barriers exist that have prevented change from occurring. The aim of this article is to explore the barriers to changing professional practice and what lessons podiatry can learn from other health care professions.

MAIN BODY

A literature search was carried out which informed a narrative review of the findings. Eligible papers had to (1) examine the barriers to change strategies, (2) explore knowledge, attitudes and roles during change interventions, (3) explore how the patients/service users contribute to the change process (4) include studies from predominantly primary care in developed countries.Ninety-two papers were included in the final review. Four papers included change interventions involving podiatrists. The barriers influencing change were synthesised into three themes (1) the organisational context, (2) the awareness, knowledge and attitudes of the professional, (3) the patient as a service user and consumer.

CONCLUSIONS

Minimal evidence exists about the barriers to changing professional practice in podiatry. However, there is substantial literature on barriers and implementation strategies aimed at changing professional practices in other health professions. Change in practice is often resisted at an organisational, professional or service user level. The limited literature about change in podiatry, a rapidly changing healthcare workforce and the wide range of contexts that podiatrists work, highlights the need to improve the ways in which podiatrists can share successful attempts to change practice.

Integrating the PILP-mineralization process into a restorative dental treatment

The addition of charged polymers, like poly-aspartic acid (pAsp), to mineralizing solutions allows for transport of calcium and phosphate ions into the lumen of collagen fibrils and subsequent crystallization of oriented apatite crystals by the so-called Polymer-Induced Liquid Precursor (PILP) mineralization process, leading to the functional recovery of artificial dentin lesions by intrafibrillar mineralization of collagen.

OBJECTIVE

To evaluate the feasibility of applying the PILP method as part of a restorative treatment and test for effectiveness to functionally remineralize artificial lesions in dentin.

MATERIALS AND METHODS

Two methods of providing pAsp to standardized artificial lesions during a restorative procedure were applied: (A) pAsp was mixed into commercial RMGI (resin modified glass ionomer) cement formulations and (B) pAsp was added at high concentration (25mg/ml) in solution to rehydrate lesions before restoring with a RMGI cement. All specimens were immersed in simulated body fluid for two weeks to allow for remineralization and then analyzed for dehydration shrinkage, integrity of cement-dentin interface, degree of mineralization, and changes in the nanomechanical profile (E-modulus) across the lesion.

RESULTS

After the remineralization treatment, lesion shrinkage was significantly reduced for all treatment groups compared to demineralized samples. Pores developed in RMGI when pAsp was added. A thin layer at the dentin-cement interface, rich in polymer formed possibly from a reaction between pAsp and the RMGI. When analyzed by SEM under vacuum, most lesions delaminated from the cement interface. EDS-analysis showed some but not full recovery of calcium and phosphorous levels for treatment groups that involved pAsp. Nanoindentations placed across the interface indicated improvement for RMGI containing 40% pAsp, and were significantly elevated when lesions were rehydrated with pAsp before being restored with RMGI. In particular the most demineralized outer zone recovered substantially in the elastic modulus, suggesting that functional remineralization has been initiated by pAsp delivery upon rehydration of air-dried demineralized dentin. In contrast, the effectiveness of the RMGI on functional remineralization of dentin was minimal when pAsp was absent.

SIGNIFICANCE

Incorporation of pAsp into restorative treatments using RMGIs promises to be a feasible way to induce the PILP-mineralization process in a clinical setting and to repair the structure and properties of dentin damaged by the caries process.

Understanding dentists' caries management: The COM-B ICCMS™ questionnaire

OBJECTIVE

To design and validate a questionnaire to measure caries management based on the Capability, Opportunity, and Motivation Behavior model (COM-B) and the International Caries Classification and Management System (ICCMS™).

METHODS

A combination of Cariology and Psychology experts developed a 79-item pool that measured the COM-B components according to the ICCMS™ caries management recommended behaviours. After face and content validation and a pilot study, two samples of Colombian dentists participated: clinicians (n = 277) and clinical-practice educators (n = 212).

RESULTS

Using parallel analysis and exploratory structural equation modelling (ESEM), the questionnaire was reduced to a 47-item 5-factor instrument that demonstrated good internal consistency and validity properties, including a robust factor structure, measurement invariance across samples and high predictive validity of ICCMS™ recommended behaviours. Scales' mean scores showed that dentists were conducting recommended behaviours "most-of-the-time" (Behavior), showed high confidence in their ability to conduct these behaviours (Capability) and considered recommendations as highly relevant (Opportunity-Relevance), while their appraisals of the available resources (Opportunity-Resources) and remuneration (Motivation) were notably lower.

CONCLUSION

Overall, the findings highlight the practical utility of the COM-B ICCMS™ Questionnaire in understanding the potential antecedent variables that may explain dentists' behaviours related to caries diagnosis and management and in suggesting avenues for achieving a positive change in their behaviour.

Systematic review finds that silver diamine fluoride is effective for both root caries prevention and arrest in older adults

Data sourcesPubMed, Pubmed Clinical Queries, EMBASE, the American Dental Associations Evidence-Based Dentistry Website, Cochrane Library, Web of Science, repository of the Journal of the American Dental Association and Google Scholar.Study selectionFour authors independently assessed the abstracts of studies resulting from the above searches which compared treatment of root caries in an older population with SDF versus other preventive agents or placebos.Data extraction and synthesisTitles and abstracts of all reports identified through the electronic searches were assessed independently by four authors based on agreed upon inclusion and exclusion criteria. Of the selected studies for final inclusion in the systematic review, study quality was assessed using the critical appraisal worksheet for randomised controlled trials from the Oxford Centre for Evidence-Based Medicine (CEBM 2005). Prevented fraction (PF), number needed to treat (NNT) and relative risk (RR) were calculated as outcome measures in each study. In addition, the published evidence on SDF was reviewed in order to formulate clinical recommendations on safety and effectiveness when treating root or coronal caries in an adult population with SDF, as well as treatment of dental hypersensitivity.ResultsThree randomised controlled trials were identified that addressed the effectiveness of SDF on root caries in older adults, but none addressed coronal caries. Root caries prevented fraction and arrest rate for SDF were significantly higher than placebo. The prevented fraction for caries prevention for SDF compared to placebo was 71% in a three-year study and 25% in a two-year study. The prevented fraction for caries arrest for SDF was 725% greater in a 24-month study and 100% greater than placebo in a 30-month study. No severe adverse effects were observed.ConclusionsExisting reports of SDF trials support effectiveness in root caries prevention and arrest, remineralisation of deep occlusal lesions and treatment of hypersensitive dentine.

Implementation and trial evidence: a plea for fore-thought

In a world where evidence-based practice is see as the foundation of modern healthcare, this paper asks when and how should we be accounting for the input of patients, the public, dental professionals, commissioners and policy-makers in the evidence generation process?

Restorative Thresholds for Carious Lesions: Systematic Review and Meta-analysis

Current evidence supports noninvasive/nonrestorative treatment of "early" carious lesions: those confined to enamel or reaching the enamel-dentin junction. The extent that dentists' thresholds for intervening restoratively have changed with this evidence is unknown. This systematic review aimed to determine dentists' and therapists' current lesion threshold for carrying our restorative interventions in adults/children and primary/permanent teeth. Embase, Medline via PubMed, and Web of Science were searched for observational studies, without language, time, or quality restrictions. Screening and data extraction were independent and in duplicate. Random-effects meta-analyses with subgroup and meta-regression analysis were performed. Thirty studies, mainly involving dentists, met the inclusion criteria. There was heterogeneity in sampling frames, methods, and scales used to investigate thresholds. The studies spanned 30 y (1983-2014), and sample representativeness and response bias issues were likely to have affected the results. Studies measured what dentists said they would do rather than actually did. Studies represented 17 countries, focusing mainly on adults ( n = 17) and permanent teeth ( n = 24). For proximal carious lesions confined to enamel (not reaching the enamel-dentin junction), 21% (95% confidence interval [CI], 15%-28%) of dentists/therapists would intervene invasively. The likelihood of a restorative intervention almost doubled (risk ratio, 1.98; 95% CI, 1.68-2.33) in high caries risk patients. For proximal lesions extending up to the enamel-dentin junction, 48% (95% CI, 40%-56%) of dentists/therapists would intervene restoratively. For occlusal lesions with enamel discoloration/cavitation but no clinical/radiographic dentin involvement, 12% (95% CI, 6%-22%) of dentists/therapists stated they would intervene, increasing to 74% (95% CI, 56%-86%) with dentin involvement. There was variance between countries but no significant temporal trend. A significant proportion of dentists/therapists said they would intervene invasively (restoratively) on carious lesions where evidence and clinical recommendations indicate less invasive therapies should be used. There is great need to understand decisions to intervene restoratively and to find implementation interventions that translate research evidence into clinical practice.