Restoration Repair as a Contemporary Approach to Tooth Preservation: Criteria for Decision Making and Clinical Recommendations

Primary care dentistry: Past, present and future

This article examines the past, present and future of primary care dentistry. It provides a historical background of primary care dentistry and describes stages of its evolution. It further reviews the purpose and mission of contemporary primary care dentistry and outlines a vision for the development of primary care dentistry in the future. The type and extent of innovations and technological advances that have impacted - and improved - primary care dentistry revolutionising clinical activities, ranging from early computerised tomography to modern digital systems and workflows are summarised. A discussion of current scientific evidence base pertinent to primary care dentistry highlighting the need for 'effectiveness' rather than 'efficacy' studies is included in order to provide research data pertinent to the primary care dentistry setting where most dental patients receive most of their care most of the time.

EVIDENCE-PRACTICE GAP IN TREATMENT DECISIONS ABOUT DEFECTIVE COMPOSITE AND AMALGAM RESTORATIONS AMONG BRAZILIAN DENTISTS

Better understanding of dentists' decision-making about defective restorations is needed to close the evidence-practice gap (EPG). Aim: this study aimed to quantify the EPG about defective restorations and identify dentist factors associated with this EPG. Methods: 216 dentists from São Paulo State, Brazil, completed a questionnaire about three clinical case scenarios involving defective composite restorations with cementum-dentin margins (case 1) and enamel margins (case 2), and an amalgam (case 3) restoration. Dentists were asked what treatment, if any, they would recommend, including preventive treatment, polishing, re-surfacing, or repairing the restoration, or replacing the entire restoration. Replacing the entire restoration in any of these three scenarios was classified as inconsistent with the evidence, comprising an EPG. Bivariate analyses using Chi-square, ANOVA, or multiple comparison tests were performed (p<.05). Results: for defective composite restorations, 49% and 55% of dentists chose to replace the entire restoration for cases 1 and 2, respectively. Twenty-nine percent of dentists chose to replace the entire amalgam restoration. Dentists were significantly more likely to choose to replace the defective amalgam restoration than the composite restoration with a defect at the cementum-dentin margins or the enamel margins (both at p < .001). Female dentists were more likely to choose a conservative treatment than male dentists for cases 1 (p=.034) and 2 (p=.009). Dentists with a higher percentage of patients interested in individualized caries prevention were also more conservative in case 1 (p=.045). Conclusion: a substantial EPG regarding treatment decisions for defective restorations exists, especially for composite restorations. This study adds to the international evidence that an EPG exists in this clinical area and that global strategies need to be developed to close the gap.

Effects of silane coupling treatment on the clinical performance of direct repaired resin-based composite (RBC) restorations with or without prior surface sandblasting: A randomized controlled trial

OBJECTIVE

To evaluate the effects, of using silane coupling agent within the procedures of repairing old composite restorations with or without sandblasting their surfaces, on the clinical performance of repaired composite restorations.

METHODS

The study involved repairing 130 Class I and II defective composite restorations. After recurrent caries removal, the repair process included etching with 37 % phosphoric acid, Adper Single Bond 2 application for bonding and Filtek Z250 composite for restoring all defects. The restoration surfaces were subjected to one of the following additional surface treatments within the repair process: Control: No additional treatment; the Silane-Adhesive treatment: A separate step involved the application of a silane coupling agent after acid etching; and the Sandblast-Silane-Adhesive treatment: included intra-oral sandblasting of old composite surfaces followed by silane application. Two calibrated examiners evaluated all repaired restorations according to a modified USPHS criteria after 6 months. Comparisons of the clinical performance between the treatment groups were made using Chi-square test, while responses to cold tests before and after repair treatment were made using Wilcoxon's Signed Rank's (α = 0.05).

RESULTS

Of 130 cases, only 116 cases turned up for evaluation. The primary reasons for composite repair were recurrent caries and anatomical deficiencies. No statistically significant differences were found between the groups for all clinical criteria (p > 0.05). The control group experienced one total and two partial retention losses.

CONCLUSIONS

The application of a silane coupling agent, with or without intra-oral sandblasting, demonstrated no improvement on the clinical performance of repaired posterior composites after 6-months.

CLINICAL SIGNIFICANCE

Surface treatment of defective composite restorations using silane with intra-oral sandblasting within their repair process offered marginal improvement in their clinical performance over conventional etching technique, but insignificantly so. Repair reduced exaggerated cold test responses and eliminated POS within 6-months. Repair reduces cold sensitivity and promotes restoration longevity. This clinical trial was registered at ClinicalTrials.gov with the registration number NCT06005571.

Reframing perceptions in operative dentistry relating evidence-based dentistry and clinical decision making: a cross-sectional study among Jordanian dentists

BACKGROUND

The aim of the current study was to investigate current dental practice in operative dentistry in Jordan, and the relationship between evidence-based dentistry in caries research and decision making in clinical practice in operative dentistry.

MATERIALS AND METHODS

This cross-sectional study was conducted through a survey of dentists in Jordan. The survey aimed to explore the degree of knowledge and practice of evidence-based dentistry in caries research the dentists possess regarding clinical decision making in operative dentistry. The sample size was composed of (5811) dentists whom registered in Jordan Dental Association database. Descriptive statistics were generated and Chi-square test was used to examine associations between the different variables and the significance level was set at P < 0.05.

RESULTS

4000 responses were collected from the web-survey, response rate (68.83%). Nearly half of the surveyed dentists focus on the chief complaint of their patients (n = 2032, 50.8%) rather than doing full mouth assessment. Nearly two-thirds of dentists (n = 2608, 65.2%) treat lesions confined to enamel with operative treatment. Half of dentists use operative treatment when asked about the routine management of radiographically detected proximal caries confined to enamel. When treating incipient lesions, the majority (n = 3220, 80.5%) use preventive treatment. Three-quarters of dentists (n = 2992, 74.8%) treat deep dentinal caries by removing just the soft infected carious dentin, and treated old failed restorations with replacement.

CONCLUSION

In operative dentistry, the evidence-based research is not implemented clinically. To optimize relationship between evidence-based dentistry and clinical decision-making, dental curriculum has to be updated and modified constantly.

Scanning Electron Microscope Image Analysis of Bonding Surfaces following Removal of Composite Resin Restoration Using Er: YAG Laser: In Vitro Study

It is impossible to remove tooth-colored restorations by mechanical means without unnecessary damage to the adjacent sound tooth structure. This study is aimed at investigating erbium-doped yttrium aluminum garnet (Er: YAG) laser (Hoya ConBio, VersaWave, CA, USA) in removing composite resin restorations and assessing the change in morphology of bonding surfaces using a scanning electron microscope (EDX, CAMSCANNER, 3200LV, UK). The investigators collected thirty extracted sound human premolar teeth for this investigation, and the conventional design class V cavity was prepared on the buccal surface of each specimen. The specimens were allocated randomly into three groups, according to the procedure used for the ablation of the composite restoration: group A (high-speed diamond fissure bur), group B, and group C (Er: YAG laser) using a different pulse repetition rate of 20 Hz (group B) and 25 Hz (group C). The AutoCAD software program (Autodesk, Inc., 2016) was used to calculate the surface area and the resulting dimensional change of the cavities after restoration removal. The cavities were filled with composite resin and randomly assigned into two groups conforming to the methods applied to eliminate the restoration; diamond turbine fissure bur and laser. In each group, two specimens were selected randomly for scanning electron microscope analysis of bonding surfaces. The least meantime for the composite resin removal was observed in the high-speed diamond bur, significantly less than both Er-YAG laser groups (p < 0.001). However, at a higher pulse repetition rate, time-consuming decreased. The results showed that laser is more conservative in removing composite resin restoration as the change was most remarkable in group A (0.800 mm), then group C (0.466 mm), and the slightest change is in group B (0.372 mm) (p = 0.014). The dentin surface of group A showed a smooth surface with no opened dentinal tubule and intact smear layer. In groups B and C, dentin surfaces were irregular, scaly, or flaky, and dentinal tubules were opened without a smear layer. Therefore, Er: YAG laser is effective for composite resin removal considering the parameters chosen in this study with fewer changes in cavity surface area and better microretentive features.

Teaching of the repair of defective composite restorations in Middle Eastern and North African Dental Schools

OBJECTIVES

To evaluate the status of teaching of repair of defective resin-based composite restorations in dental schools in the Middle Eastern and North African (MENA) countries.

METHODS

A validated 14-item questionnaire was mailed to the directors of the operative/restorative dentistry department in 40 MENA dental schools. Data were collected on teaching, including whether the repair of resin-based composite restorations was part of the dental school curriculum; the rationale behind the teaching; how techniques were taught, indications for repair, operative techniques, materials used, patient acceptability and expected longevity of the repair procedure.

RESULTS

Thirty-two schools responded to the survey (response rate of 80%). Twenty-two (69%) schools reported the teaching of resin-based composite repairs as an alternative to the replacement of restorations. Of the schools not teaching repairs, 80% indicated that they plan to include this topic in the curriculum within the next five years. Most schools taught theoretical and practical aspects of repair at a clinical level only. Two-thirds of schools reported tooth substance preservation being the main reason for teaching repair techniques. The main indications for repair treatment were marginal defects (59%), followed by partial loss of restoration (56%). Most schools that performed repairs reported high patient acceptability. Considerable variation was noted in relation to expected longevity of resin- based composite repairs.

CONCLUSIONS

The repair of defective resin-based composite restorations is actively taught within most of the surveyed schools. Advantages of repair, compared to replacement include minimum intervention, preservation of tooth structure, and savings of time and cost.

CLINICAL SIGNIFICANCE

The decision between replacing or repairing a defective resin-based composite restoration in the MENA region tends to be based on clinicians' subjective experience and judgement. However, to further enhance the teaching of resin-based composite repair standardised guidelines need to be developed based on existing evidence.

Facts and Fallacies About Restorative Philosophies for the Management of the Worn Dentition

This article addresses facts and fallacies about managing worn teeth and challenges some traditional concepts and beliefs about occlusion. Whilst it is accepted that many of the historic occlusal concepts were well intended, closer examination reveals that many were unnecessarily destructive of sound tooth tissues and did not deliver all of their purported benefits. Those fallacies make them less appropriate in the litigious environment of contemporary dental practice. This paper discusses the disadvantages of 'subtractive' dental procedures for the management of tooth wear, and highlights the benefits of proven minimally destructive 'additive' techniques.