Repair versus replacement of defective direct restorations: A cross-sectional study among US dentists

BACKGROUND

Repair increases the longevity of restorations and is well-accepted by patients. In this study, the authors assessed the acceptance of dental restoration repair by dentists and determined the main variables of repair versus replacement of defective restorations.

METHODS

A 15-item questionnaire was developed and distributed electronically to the American Dental Association Clinical Evaluators panel members (n = 785) during a 2-week period in 2019. Descriptive, bivariate, and multivariable analyses were conducted.

RESULTS

Of the 387 respondents, 83.7% stated that they repair defective restorations, and 16% stated that they always replace them. Reasons to forego a restoration repair among dentists who perform repairs included defect size and carious lesion extension (42%) and negative personal experience or lack of success (37.9%). However, the latter was considerably higher for dentists who do not perform repairs (60.7%). The most commonly cited patient-related reason and tooth condition to repair restorations were limited patient finances (67%) and noncarious marginal defects (86%), respectively. Neither sex nor age group was significantly associated with the practice of restoration repair (P = .925 and P = .369, respectively). However, sole proprietors were more likely to perform repairs than those in an employee, associate, or contractor practice setting (P = .008). The most significant reason to forego restoration was negative experience or lack of success (P = .002).

CONCLUSIONS

Restoration repair is considered a treatment option for managing defective restorations. Negative personal experience or lack of success and practice setting influenced the dentists' decision to repair or replace a defective restoration.

PRACTICAL IMPLICATIONS

Understanding dentists' clinical challenges and practice environment is necessary when advocating for this approach.

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

BACKGROUND

An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated evidence-based clinical recommendations for the arrest or reversal of noncavitated and cavitated dental caries using nonrestorative treatments in children and adults.

TYPES OF STUDIES REVIEWED

The authors conducted a systematic search of the literature in MEDLINE and Embase via Ovid, Cochrane CENTRAL, and Cochrane database of systematic reviews to identify randomized controlled trials reporting on nonrestorative treatments for noncavitated and cavitated carious lesions. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and move from the evidence to the decisions.

RESULTS

The expert panel formulated 11 clinical recommendations, each specific to lesion type, tooth surface, and dentition. Of the most effective interventions, the panel provided recommendations for the use of 38% silver diamine fluoride, sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate fluoride gel, and 5,000 parts per million fluoride (1.1% sodium fluoride) toothpaste or gel, among others. The panel also provided a recommendation against the use of 10% casein phosphopeptide-amorphous calcium phosphate.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Although the recommended interventions are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.

Caries Management Decision-Making: Diagnosis and Synthesis

The purposes of this article are to (1) offer a critical thinking skill set in decision-making and synthesis for caries diagnosis, and risk-adjusted and personalized management based on emulating the intended activity of the expert, (2) offer patient/case scenarios for application of the critical thinking skill set, (3) compare and contrast the results of applying an algorithm and expert thought process approach to patient analyses, (4) offer characteristics of the person making decisions and synthesizing information, and (5) for patients with complex health and social histories, include perspectives from other health care team members.

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.

Retrospective analysis of factors associated with the success of stepwise excavation procedure in deep carious lesions

BACKGROUND

Recent scientific evidence regarding the stepwise excavation procedure (SWP) has not addressed the consideration of patient factors when selecting SWP as treatment for deep carious lesions (DCLs). This study assessed patient factors predicting a successful SWP defined as a tooth restored with SWP and did not result in root canal treatment or a dental extraction.

METHODS

SWPs completed in 626 patients without symptomatic irreversible pulpitis at the University of Iowa College of Dentistry from January 2004 through December 2012 were evaluated. Patient demographic and tooth-specific characteristics were assessed in their relationship with the main outcome.

RESULTS

SWPs had a 75% success rate when evaluated within 36 months of the initial treatment. Findings showed that patients who had successful SWP treatment of DCLs were somewhat younger than patients whose SWP treatment was not successful (mean age, 37.4 years and 40.5 years, respectively; odds ratio, 0.981; 95% confidence interval, 0.967 to 0.994; P = .0058). Patients who returned to their second appointment within 5 to 9 months were more likely to have a successful SWP treatment than those returning sooner than 5 months (odds ratio, 0.338; 95% confidence interval, 0.210 to 0.545; p < .0001).

CONCLUSION

Treatment of deep carious lesions with SWP is effective for pulp preservation and patient age may influence the outcome.

PRACTICAL IMPLICATIONS

Although a somewhat younger mean patient age was associated with successful treatment of DCLs, SWP can be successful regardless of patient age and clinicians should consider SWP in treating DCLs.

Evidence-based dentistry: assessment to document progression to proficiency

INTRODUCTION

The integration of evidence-based dentistry (EBD) into pre-doctoral dental curricula requires the identification of desired outcomes, development of curricular content and design of assessment strategies which guide student performance whilst documenting achievement of desired curricular outcomes. Models for developing EBD curriculums have been described in the literature; however, the logistics of designing assessment instruments to progressively document student performance have received less attention. The objective of this article is to describe the University of Iowa's College of Dentistry's development and implementation of assessment strategies to guide student learning of EBD knowledge, application and assimilation to serve as a model for other institutions developing EBD assessment protocols.

ASSESSMENT DEVELOPMENT

Desired EBD knowledge and behaviour outcomes guided the development of curricular content and progressive formative and summative assessment strategies. Vertically and horizontally integrated educational activities enabling students to demonstrate EBD knowledge whilst modelling desired behaviours were identified, whilst assessment principles guided development of learning guides and assessment instruments to document achievement of desired outcomes. Consistent EBD language and educational activities are utilised throughout the 4-year interdisciplinary curriculum with stepwise assessment protocols matched to the curriculum. Examples of student learning guides and assessment instruments are provided.

SUMMARY

Curricular design guides development of assessment strategies. Assessment protocols provide consistent formative and summative feedback to enable continuous student growth to become proficient EBD practitioners.

Exploring How U.S. Dental Schools Teach Removal of Carious Tissues During Cavity Preparations

Approaches for managing carious tissues during cavity preparations vary considerably among clinicians, which may reflect inconsistencies in the teaching of this subject by dental schools. The aims of this study were to investigate practices related to the preclinical and clinical teaching of caries removal at U.S. dental schools and the relationship between that teaching and requirements for U.S. dental licensure examinations. The electronic survey included questions about terminology, methods, instruments and materials, treatment planning, criteria for clinical exams, faculty calibration sessions, and licensure exams. The faculty members at U.S. dental schools responsible for teaching cariology were invited to participate; 54 of the 65 schools had identified a contact person at the time of the survey in October 2015. Of those 54 invited to participate, 43 completed the survey (response rate of 79.6%). Most of the respondents indicated that depth of carious lesions was a clinical determinant of the amount of carious dentin being removed in cavity preparations. Caries removal was used as a criterion in restorative clinical examinations by 95% of responding schools. Marked differences were observed regarding the criteria used for assessment and removal of carious tissues, management of deep carious lesions, and definition of "caries remaining at cavity preparations," which is considered a critical error on licensure exams. Faculty calibration sessions on caries removal were reported to occur in 65% of these schools and at different time frames. Overall, the study found a wide range of teaching practices related to caries removal. Best evidence in caries management needs to be aligned with teaching and the criteria used to calibrate faculty members and examiners.

Development of a Core Curriculum Framework in Cariology for U.S. Dental Schools

Maintenance of health and preservation of tooth structure through risk-based prevention and patient-centered, evidence-based disease management, reassessed at regular intervals over time, are the cornerstones of present-day caries management. Yet management of caries based on risk assessment that goes beyond restorative care has not had a strong place in curriculum development and competency assessment in U.S. dental schools. The aim of this study was to develop a competency-based core cariology curriculum framework for use in U.S. dental schools. The Section on Cariology of the American Dental Education Association (ADEA) organized a one-day consensus workshop, followed by a meeting program, to adapt the European Core Cariology Curriculum to the needs of U.S. dental education. Participants in the workshop were 73 faculty members from 35 U.S., three Canadian, and four international dental schools. Representatives from all 65 U.S. dental schools were then invited to review and provide feedback on a draft document. A recommended competency statement on caries management was also developed: "Upon graduation, a dentist must be competent in evidence-based detection, diagnosis, risk assessment, prevention, and nonsurgical and surgical management of dental caries, both at the individual and community levels, and be able to reassess the outcomes of interventions over time." This competency statement supports a curriculum framework built around five domains: 1) knowledge base; 2) risk assessment, diagnosis, and synthesis; 3) treatment decision making: preventive strategies and nonsurgical management; 4) treatment decision making: surgical therapy; and 5) evidence-based cariology in clinical and public health practice. Each domain includes objectives and learning outcomes.

Factors Associated with Reevaluation of the Stepwise Excavation Procedure: An 8-Year Retrospective Study

Although the stepwise excavation procedure (SWP) has been shown to be an effective caries treatment technique, studies reporting its application outside of controlled clinical trials are limited. We performed a retrospective study from patient record data to assess the proportion of patients who had an SWP reevaluated within 18 months at The University of Iowa College of Dentistry (UICOD) between 2004 and 2012, and evaluated the association between different variables and this outcome. A total of 1,985 SWPs were performed in 1,326 patients, with 518 patients having had reevaluation within 18 months. Bivariate analysis and logistic regression modeling revealed strong associations between explanatory variables such as provider type, tooth type, patient age, number of recalls and the calendar year in which the SWP was done and reevaluation status. There was also evidence of association with dental insurance status. Other characteristics such as gender, distance traveled to the UICOD, number of surfaces treated and tooth arch did not show any significant association. In general, patients were more likely to have reevaluation when seen by faculty members or residents, the procedure was performed in molars/pre-molars, they were older, they had more recalls and were seen earlier in the study period. These results suggest that decisions to use SWP should consider patient demographics and treatment characteristics such as provider level, tooth type, patient age and number of recalls. The impact of treatment year may reflect program heterogeneity or temporal changes in external societal factors.

Conservative treatment planning in veneer replacement

This clinical report describes a conservative treatment in veneer replacement where diastemas, malalignment, and midline shift were the main modifying factors. When replacement veneers are indicated, the definitive results can only be accurately predicted after an esthetic reanalysis of the existing restorations.

Fluorescence changes in remineralized and nonremineralized enamel adjacent to glass ionomer ART restorations: an in vitro study

PURPOSE

The purpose of this study was to evaluate fluorescence changes of remineralized and nonremineralized enamel margins adjacent to glass ionomer restorations during a pH cycling sequence.

METHODS

One hundred permanent molar and premolar teeth were placed in a demineralizing solution for 3 days and restored with a glass ionomer restoration (simulating Atraumatic Restorative Treatment [ART]). Half were placed in a remin solution for 7 days to create a remineralization (remin) group. Specimens were randomly divided into 4 groups (N=25): (a) 2 remin groups; and (b) 2 nonremin groups. One half of the remin and nonremin group specimens were treated with a 5,000-ppm sodium fluoride solution during pH cycling with remin fluid and an acidic beverage over 20 days. Fluorescence changes were recorded with quantitative light fluorescence (QLF). Higher fluorescence values indicated less lesion porosity. Statistical comparisons between the groups over the 5 measurement sessions of cycling were performed using repeated measures of analysis of variance with a post-hoc test, paired-sample t test and 2-sample t tests (alpha=0.05).

RESULTS

The remin groups experienced significantly less lesion porosity than the nonremin groups. Fluoride groups experienced less lesion porosity than the nonfluoride groups.

CONCLUSIONS

A brief period of remineralization and use of a prescription strength fluoridated rinse improved the enamel substrate surrounding glass ionomer restorations, resulting in less lesion porosity.

Management of high caries risk and high caries activity patients: rampant caries control program (RCCP)

The purpose of this article is to describe the Rampant Caries Control Program established in the operative dentistry third-year clinic at the University of Iowa College of Dentistry. This program represents a new approach to the management of high caries risk and high caries activity patients who come to the school. The patients are referred initially to the third-year operative clinic only for disease control (phase I) to help them decrease the caries risk and activity. The disease control phase has three important components: 1) caries risk assessment evaluation and reevaluation throughout their treatment, in which individual risk factors are identified and recommendations are made; 2) caries removal and placement of transitional restorations using fluoride release restorative materials (glass ionomers); and 3) chemotherapeutic agents and preventive treatment in which a therapeutic regimen for prevention and nonsurgical treatment is established according to each patient's individual risk factors. About 50 percent of patients have dropped from the program, 36 percent currently are under disease control treatment, and 14 percent have finished the disease control phase of the program. After the disease is controlled through modification of risk factors and activity, the patients can be referred for reevaluation prior to beginning the rehabilitation phase.

Rampant caries

Although dental caries in the pediatric and adolescent population has consistently declined in the United States, it is still the most common childhood disease. Dental problems are the number one reason for missing school next to the common cold. Dental caries are an infectious, communicable disease resulting in destruction of tooth structure by acid-forming bacteria found in dental plaque, an intraoral biofilm, in the presence of sugar. The etiology of rampant disease is very complex. It is multifactorial and has a close relationship to a number of risk factors. It is important that school nurses identify patients at risk for dental caries early to determine their risk and refer them for disease prevention and control.

Relationship between nanoleakage and microtensile bond strength at the resin-dentin interface

To evaluate the correlation between microtensile dentin bond strength (microTBS) and silver ion penetration, two total-etch 3-step and one self-etch 2-step system were investigated. OptiBond FL adhesive was applied to flat occlusal dentin on six non-carious human molars, and a resin composite "crown" was formed in 2 mm increments. After 24-hour water storage, the teeth were sectioned with a low-speed diamond saw to obtain four-square sticks (approximately 2 mm X 2 mm) per tooth. Cylindrical tensile test specimens were formed with an 0.5 mm2 cross-sectional area. Nail varnish was applied to the dentin within 0.5-1.0 mm of the interface before immersing in 50% silver nitrate for 15 minutes. Following silver fixation, tensile testing was performed in a Zwick UTM at 1 mm/minute using a passive gripping fixture to obtain 72-hour microTBS [23.9 MPa]. The percentage area of silver penetration was measured on debonded specimens using light microscopy and Image-Pro Plus Software [89%]. The procedures were repeated using Scotchbond Multi-Purpose Plus [microTBS = 27.8 MPa; nanoleakage = 67%] and Clearfil SE bond [microTBS = 36 MPa; nanoleakage = 55%]. No significant correlation between microtensile bond strength and nanoleakage was found for all systems. A weak-to-moderate negative relationship was found between microTBS and nanoleakage for OptiBond FL (Spearman r = -0.3844). No correlation was found for the remaining adhesive systems. The correlation between these two common laboratory measurements appears to be adhesive-system dependent.

Surface coating and leakage of dentin-bonded resin composite restorations

OBJECTIVES

To compare the marginal leakage of dentin-bonded resin composite restorations in tooth sections coated with nail varnish and similarly restored sections coated with cyanoacrylate cement.

METHODS

MO and DO cavities were prepared with the gingival floor below the CEJ in 11 non-carious extracted human molars. Each cavity was restored with a dentin adhesive and resin composite. Sectioning yielded four specimens per tooth (N=44). One specimen from each restoration was coated with varnish. The other specimen was coated with cyanoacrylate cement. The coatings were applied to all surfaces except that a 1mm window on either side of the interproximal gingival margin was left uncoated. Specimens were thermocycled and stained with silver nitrate. Silver penetration into the gingival margin of each section was measured with a measuring microscope. The predominant leakage path for each coating type was determined by scanning electron microscopy.

RESULTS

There was no significant difference between the leakage of the varnish-coated and cyanoacrylate-coated specimens. No marginal gaps were observed either by optical or by electron microscopy. However, the both optical and electron microscopy revealed leakage in nearly all specimens. This leakage was confined to either the dentin/hybrid layer interface or the adhesive resin/hybrid layer interface.

CONCLUSIONS

The results suggest that these coating materials are not confounding factors in laboratory investigations of marginal leakage along dentin-bonded interfaces of resin composite restorations. Although marginal gaps were undetectable even at high magnification, leakage was observed along the gingival margin of almost all of these Class II resin composite restorations.