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Dhar V, Pilcher L, Fontana M, González-Cabezas C, Keels MA, Mascarenhas AK, Nascimento M, Platt JA, Sabino GJ, Slayton R, Tinanoff N, Young DA, Zero DT, Pahlke S, Urquhart O, O'Brien KK, Carrasco-Labra A. Evidence-based clinical practice guideline on restorative treatments for caries lesions: A report from the American Dental Association. J Am Dent Assoc 2023; 154:551-566.e51. [PMID: 37380250 DOI: 10.1016/j.adaj.2023.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/07/2023] [Accepted: 04/01/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth. TYPES OF STUDIES REVIEWED The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations. RESULTS The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios. PRACTICAL IMPLICATIONS The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.
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Silva GSD, Raggio DP, Mello-Moura ACV, Gimenez T, Montagner AF, Floriano I, Lara JS, Calvo AFB, Pascareli-Carlos AM, Tedesco TK. Pulp vitality of primary molars with deep caries treated with ART restorations: 2-year RCT. Braz Oral Res 2022; 36:e061. [PMID: 36507748 DOI: 10.1590/1807-3107bor-2022.vol36.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 12/01/2021] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to compare the pulp vitality of primary teeth with deep caries treated with two restorative techniques. The restoration survival rate was also evaluated as a secondary outcome. Children aged from 4 to 8 years with at least one deep carious lesion in molars were selected at the Ibirapuera University dental clinic. One hundred and eight deciduous molars were allocated into two groups: (1) restoration with calcium hydroxide cement lining followed by filling with high-viscosity glass ionomer cement (CHC+HVGIC) or (2) restoration with HVGIC. Pulp vitality and restoration survival were evaluated at 6, 12, and 24 months. Intent-to-treat analysis was used for pulp vitality, and survival analysis was performed with the Kaplan-Meier method (α=5%). Results: At 24 months, 86 restorations were evaluated, and 91 were evaluated at least once during the study. There was no significant difference between the restorative treatments regarding pulp vitality (CHC +HVGIC=70% and HVGIC=68.5%) (OR=1.091; CI95%=0.481-2.475). However, HVGIC (73%) restorations showed a higher survival rate than CHC+HVGIC (50%) (p=0.021). Thus, it can conclude that deep caries in primary molars should be restored with HVGIC, since the technique results in similar pulp vitality to the CHC +HVGIC, but with a higher restoration survival rate.
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Affiliation(s)
- Gabriela Seabra da Silva
- Universidade de São Paulo - USP, School of Dentistry, Department of Orthodontics and Pediatric Dentistry, São Paulo, SP, Brazil
| | - Daniela Prócida Raggio
- Universidade de São Paulo - USP, School of Dentistry, Department of Orthodontics and Pediatric Dentistry, São Paulo, SP, Brazil
| | - Anna Carolina Volpi Mello-Moura
- Universidade Católica Portuguesa, Faculty of Dental Medicine, Center for Interdisciplinary Research in Health - SalivaTec Lab, Viseu, Portugal
| | - Thais Gimenez
- Universidade Ibirapuera - UNIB, Graduate Program in Dentistry, São Paulo, SP, Brazil
| | | | - Isabela Floriano
- Centro Universitário Uninovafapi, School of Dentistry, Teresina, PI, Brazil
| | - Juan Sebastian Lara
- Indiana University, School of Dentistry, Department of Cariology, Operative Dentistry and Dental Public Health, Indianapolis, IN, USA
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Schwendicke F, Walsh T, Lamont T, Al-Yaseen W, Bjørndal L, Clarkson JE, Fontana M, Gomez Rossi J, Göstemeyer G, Levey C, Müller A, Ricketts D, Robertson M, Santamaria RM, Innes NP. Interventions for treating cavitated or dentine carious lesions. Cochrane Database Syst Rev 2021; 7:CD013039. [PMID: 34280957 PMCID: PMC8406990 DOI: 10.1002/14651858.cd013039.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC). OBJECTIVES To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps. SEARCH METHODS An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies. SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions). DATA COLLECTION AND ANALYSIS Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions. MAIN RESULTS We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth. Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing with sealant materials (2); sealant materials versus no sealing (2). Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT. AUTHORS' CONCLUSIONS Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.
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Affiliation(s)
- Falk Schwendicke
- Department of Oral Diagnostics, Digital Health and Health Research Services, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tanya Walsh
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Thomas Lamont
- School of Dentistry, University of Dundee, Dundee, UK
| | - Waraf Al-Yaseen
- School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Lars Bjørndal
- Cariology and Endodontics, Section of Clinical Oral Microbiology, Department of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Janet E Clarkson
- Division of Oral Health Sciences, School of Dentistry, University of Dundee, Dundee, UK
| | - Margherita Fontana
- Department of Cariology, Restorative Sciences and Endodontics, School of Dentistry, University of Michigan, Michigan, USA
| | - Jesus Gomez Rossi
- Department of Oral Diagnostics, Digital Health and Health Research Services, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Gerd Göstemeyer
- Department of Operative and Preventive Dentistry, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Colin Levey
- Division of Restorative Dentistry, School of Dentistry, University of Dundee, Dundee, UK
| | - Anne Müller
- Department of Oral Diagnostics, Digital Health and Health Research Services, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Ruth M Santamaria
- Department of Preventive and Pediatric Dentistry, University of Greifswald, Greifswald, Germany
| | - Nicola Pt Innes
- School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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Aïem E, Joseph C, Garcia A, Smaïl-Faugeron V, Muller-Bolla M. Caries removal strategies for deep carious lesions in primary teeth: Systematic review. Int J Paediatr Dent 2020; 30:392-404. [PMID: 31943437 DOI: 10.1111/ipd.12616] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/02/2019] [Accepted: 12/29/2019] [Indexed: 12/26/2022]
Abstract
The study aimed to compare the efficacy of three caries removal techniques-complete caries removal (CCR), selective caries removal (SCR), and stepwise caries removal (SWR)-for deep carious lesions in vital temporary teeth by conducting a systematic review and meta-analysis of randomized controlled trials (RCTs). Electronic databases (PubMed [MEDLINE], Cochrane Library, EMBASE) were searched for corresponding references up to 31 May 2019. Possible outcomes were pulp exposure, pulpo-periodontal complications, or restorative failures. Three reviewers independently selected studies, extracted data, and assessed the risk of bias using RoB 2. Meta-analyses for intention-to-treat and per-protocol scenarios were performed using Revman5. Of 1374 potentially eligible articles, ten relevant references corresponding to eight studies were included. Pooled results showed decreased risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using USPHS criteria, after SCR compared with CCR only in intention-to-treat analysis. Risk of clinical or radiographic failure of pulpo-periodontal complications was unchanged when compared with SCR and CCR or SWR. SCR and SWR may result in lower pulp exposure risk than CCR. RCTs with lower risk of bias, higher power, and longer follow-up are required to choose between these three caries removal techniques for deep carious lesions in vital temporary teeth.
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Affiliation(s)
- Elody Aïem
- Department of Paediatric Dentistry, Faculty of Dentistry, Nice-Côte d'Azur University, UCA, Nice, France.,Pôle d'Odontologie, CHU Nice, Nice, France
| | - Clara Joseph
- Department of Paediatric Dentistry, Faculty of Dentistry, Nice-Côte d'Azur University, UCA, Nice, France.,Pôle d'Odontologie, CHU Nice, Nice, France.,MICRORALIS, Faculty of Dentistry, Nice-Côte d'Azur University, UCA, Nice, France
| | | | - Violaine Smaïl-Faugeron
- Pôle d'Odontologie, CHU Nice, Nice, France.,Department of Paediatric Dentistry, Faculty of Dentistry, Paris Descartes University, Montrouge, France.,Department of Paediatric Dentistry, Bretonneau Hospital, APHP, Paris, France
| | - Michèle Muller-Bolla
- Department of Paediatric Dentistry, Faculty of Dentistry, Nice-Côte d'Azur University, UCA, Nice, France.,Pôle d'Odontologie, CHU Nice, Nice, France.,Laboratory URB2i - EA 4462, Paris Descartes University - Sorbonne Paris Cité, Montrouge, France
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Valério RA, Galo R, Galafassi D, Corona SAM, Borsatto MC. Four-year clinical prospective follow-up of resin composite restoration after selective caries removal using Er:YAG laser. Clin Oral Investig 2019; 24:2271-2283. [PMID: 31686235 DOI: 10.1007/s00784-019-03082-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 09/22/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The aim of this study was to longitudinally evaluate, after a 4-year period, the clinical longevity of composite resin restoration compared to the baseline, after selective caries removal in permanent molars using Er:YAG laser or bur preparation with biomodification of dentin with the use of chlorhexidine. METHODS Selective caries removal was performed on 80 teeth of 20 individuals who each had at least four active carious lesions. These lesions, located on occlusal surfaces of permanent molar counterparts, were removed using (i) Er:YAG laser biomodified with chlorhexidine, (ii) Er:YAG laser and application of deionized water, (iii) bur preparation biomodified with chlorhexidine, and (iv) bur preparation and application of deionized water. At the end of 4 years, 64 of the 80 restorations were evaluated in 16 individuals (n = 16). The restorations were evaluated, both clinically and photographically, using scanning electron microscopy (SEM) and pulp vitality analysis. The experimental data were statistically evaluated by kappa, Fisher's, and chi-square tests, with a significance level of 5%. The Kaplan-Meier test and the Cox regression analysis were used to evaluate the survival of the restorations. RESULTS After 4 years of follow-up, there was a statistically significant difference in marginal discoloration criteria for all of the groups evaluated. For marginal adaptation criteria, there was a statistically significant difference for the Er:YAG laser group biomodified with chlorhexine (p = 0.050). For clinical and radiographic evaluation of pulp vitality, there were no statistically significant differences among the groups (p = 0.806). CONCLUSION Er:YAG laser can be used for selective caries removal, regardless of dentin biomodification with chlorhexidine or application of deionized water, once it produced promising results in composite resin restorations after 4 years of follow-up, according to the criteria evaluated. The selective caries removal using Er:YAG laser or bur and the biomodification of dentin with the use of chlorhexidine did not influence the survival of composite resin restorations after the 4-year follow-up period. CLINICAL RELEVANCE Composite resin restorations applied after selective caries removal using Er:YAG laser or burs, regardless of dentin biomodification with the use of chlorhexidine or application of deionized water, showed adequate clinical behavior after 4 years of follow-up.
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Affiliation(s)
- Rodrigo Alexandre Valério
- Clinical Pediatric Dentistry Department, Ribeirão Preto School of Dentistry / São Paulo University, Café Avenue, Monte Alegre, Ribeirão Preto, SP, 14040-904, Brazil
| | - Rodrigo Galo
- Department of Dentistry, Universidade Federal do Vale do Jequitinhonha e Mucuri (UFVJM), Rodovia MGT 367 - Km 583, n° 5000 Alto da Jacuba, Diamantina, Minas Gerais, 39100-000, Brazil
| | - Daniel Galafassi
- Department of Restorative Dentistry, School of Dentistry, Meridional College-IMED, Senador Pinheiro, 304, Cruzeiro, Passo Fundo, Rio Grande do Sul, 99070-220, Brazil
| | - Silmara Aparecida Milori Corona
- Restorative Dentistry Department, Ribeirão Preto School of Dentistry / São Paulo University, Café Avenue, Monte Alegre, Ribeirão Preto, SP, 14040-904, Brazil
| | - Maria Cristina Borsatto
- Clinical Pediatric Dentistry Department, Ribeirão Preto School of Dentistry / São Paulo University, Café Avenue, Monte Alegre, Ribeirão Preto, SP, 14040-904, Brazil.
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Tjäderhane L, Tezvergil-Mutluay A. Performance of Adhesives and Restorative Materials After Selective Removal of Carious Lesions: Restorative Materials with Anticaries Properties. Dent Clin North Am 2019; 63:715-729. [PMID: 31470925 DOI: 10.1016/j.cden.2019.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Selective carious tissue-removal strategies require specific considerations in selection of restorative materials. A tight marginal seal placed over hard dentin and sound enamel is essential. For selective removal of carious tissue with permanent restoration, bioactive materials, such as high-viscosity glass-ionomer cement (HV-GIC) or calcium silicates, may be preferred over caries-affected firm or leathery dentin to improve remineralization. HV-GICs have the best clinical evidence of caries-arresting effect and demonstrate sufficient longevity as long-term provisional restorations that can later be used in open or closed sandwich restorations. As with any material, oral health maintenance remains important for long-term survival of restorations.
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Affiliation(s)
- Leo Tjäderhane
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki University Hospital, PO Box 41, Helsinki 00014, Finland; Research Unit of Oral Health Sciences, Medical Research Center Oulu (MRC Oulu), Oulu University Hospital, University of Oulu, Oulu, Finland.
| | - Arzu Tezvergil-Mutluay
- Department of Cariology and Restorative Dentistry, Adhesive Dentistry Research Group, Institute of Dentistry, Turku University Hospital, TYKS, University of Turku, Lemminkäisenkatu 2, Turku 20520, Finland
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