Clinical Recommendations on Carious Tissue Removal in Cavitated Lesions

Non-cleansable carious lesions where sealing is no longer an option should be restored in the vast majority of cases. Prior to restoring the cavity, carious tissue removal is performed, mainly to increase the longevity of the restoration. Such removal, however, should not be conducted in a way that the vital pulp is harmed. This means that in teeth with shallow or moderately deep lesions, selective removal to firm dentine is recommended, while in deep lesions (radiographically extending into the pulpal third or quarter of the dentine) selective removal to soft dentine should be performed. In permanent teeth, stepwise removal is a possible alternative, while in primary teeth the Hall Technique can be considered too. To assess carious tissue removal, the hardness of the dentine should be the primary criterion. Moisture, colour, and additional parameters (like fluorescence of bacterial porphyrins, etc.) might be used, but should be critically evaluated towards their validity and patients' benefit. There is insufficient evidence to recommend a specific single carious tissue removal method. However, hand or chemomechanical excavation seem useful, as they reduce pain and discomfort during treatment. Current evidence also does not support any specific restoration material or (bonding) strategy for restoring cavities resulting from different carious tissue removal strategies. Prior to restoring the cavity, cavity disinfection is not recommended any longer.

Sealing Carious Tissue in Primary Teeth Using Crowns: The Hall Technique

In line with reducing the invasiveness of interventions in permanent teeth and changes towards more biological approaches, there have also been moves away from traditional restorative approaches to managing primary teeth where carious dentine/lesions were completely excised and a restoration placed. The Hall Technique is a method for managing carious primary molar teeth where a preformed stainless-steel crown, also known as a preformed metal crown, is seated over a tooth, sealing in, and not removing carious tissue. This chapter discusses the rationale behind the Hall Technique, an outline of the clinical procedure to carry it out, its indications and contraindications, together with the evidence supporting its use. The Hall Technique has been found to be acceptable to children and preferred to more invasive treatment options. Like all dental treatment options, it requires careful case selection, precise carious lesion and pulpal status diagnosis (clinically and radiographically), good patient management, and excellent parental cooperation. The Hall Technique has been shown to be a durable (being likely to last the lifespan of the primary molar) and economical management option for primary molars with carious lesions, which in addition offers the benefit of full coronal coverage, reducing the risk of future carious lesion development. As part of our everyday armamentarium in paediatric dentistry, the Hall Technique is an effective management option for controlling carious lesions in primary molars.

Selective Removal of Carious Tissue

Describing and quantifying how much carious tissue should be removed prior to placing a restoration has been a long-debated issue stretching back as far as G.V. Black's "complete caries removal," now known as non-selective carious tissue removal. Originating in the 1960s and 1970s, from the differentiation between different layers of carious dentine, an outer contaminated ("infected") layer and an inner demineralised ("affected") layer, the former of which needed to be removed during cavity preparation and the latter not, selective carious tissue removal was born. Currently, it is termed selective removal to firm dentine. This chapter describes different selective carious tissue removal techniques (to firm, to leathery, to soft dentine) and how they can be achieved appropriately with conventional and novel techniques. Selective removal to firm dentine is recommended for shallow or moderately deep lesions, while for deep lesions (extending close to the pulp) in teeth with vital pulps, selective removal to soft dentine is recommended to avoid pulpal exposure and to preserve the health of the pulp. Leaving soft carious dentine beneath a restoration does, however, raise certain issues regarding how we truly assess pulpal health, what would other dental practitioners think if the patient moved practice, and how do we monitor such sealed residual caries in the future. These issues will all be discussed in this chapter but should at present not preclude dental practitioners from adopting such a minimally invasive evidence-based approach to carious tissue removal.

Evaluation of the marginal integrity of a bioactive restorative material

This in vitro study evaluated the marginal microleakage of a bioactive restorative with other restorative materials in standard Class V preparations. Sixty previously extracted, noncarious human molars were randomly assigned to 3 experimental groups (n = 20): a bioactive composite resin, a universal hybrid composite resin, and a resin-modified glass ionomer restorative. Class V cavities were prepared on the facial or lingual surface of each tooth so that coronal margins were located in enamel and apical margins in cementum (dentin). After the cavity preparations were restored with the appropriate material, the specimens were artificially aged in water baths. The root apices were sealed with utility wax, the tooth surfaces were coated with nail varnish to within 1 mm of the restoration, and specimens were immersed in 1% methylene dye solution for 8 hours. The teeth were invested in clear polymer resin, sectioned longitudinally, and examined under a stereomicroscope to assess dye penetration. Nonparametric scores indicated that microleakage was significantly greater at the apical margins than the coronal margins for all groups (P > 0.0001). The specimens restored with the bioactive material exhibited greater microleakage at both the coronal and apical margins than did specimens restored with the composite resin or resin-modified glass ionomer material, although the differences were not statistically significant (P > 0.05). Based on the results of the present study, the type of restorative material did not appear to have a significant influence on microleakage. Rather, the marginal position (coronal versus apical) of the restoration was the determining factor in microleakage.

Evaluation of Interfacial Gap Volume of Two Low-shrinkage Composites Using Micro-Computed Tomography

OBJECTIVES

To investigate the efficacy of X-ray micro-computed tomography (μCT) in the detection and quantification of interfacial gap formation in standardized Class I and Class II resin composite restorations, to compare the interfacial gaps for two low-shrinkage resin composites with a methacrylate composite material, and to determine any correlation between the cavity configuration factor (C-factor) and the volume of gaps formed.

METHODS AND MATERIALS

Sixty standardized Class I and Class II cavities were prepared and divided into six groups. Three types of composites, with their recommended self-etching adhesive systems, were used: Filtek Z250 XT; Estelite Sigma Quick; and Filtek P90. Each of the composite materials was placed in 10 Class I and 10 Class II cavities. The specimens were digitized using Skyscan 1172 μCT. They were examined for gap volume measurements, the thickness of the adhesive layer, and location of interfacial gaps.

RESULTS

There was a significant difference in the mean gap volume percentages of the three materials. The gap volume percent of Estelite Sigma quick was significantly lower than that of Filtek P90. No significant difference in the mean gap volume percentages of Class I and Class II restorations was found, except for Estelite Sigma Quick, in which the Class I gap volume percentage was higher than that of the Class II restorations.

CONCLUSIONS

μCT is an efficacious tool for the measurement of volumetric gaps formed at the tooth/restoration interface and for the evaluation of the adhesive layer. The differences in the C-factor do not always have a pronounced effect on the gap volumes of low-shrinkage composites.

A Clinical Study on the Effect of Injection Sites on Efficacy of Anesthesia and Pulpal Blood Flow in Carious Teeth

This randomized clinical trial evaluated the efficiency of maxillary infiltration anesthesia in carious teeth at two different injection sites and their impact on the laser Doppler recordings of pulpal blood flow (PBF) during a caries excavation procedure. The null hypothesis tested was that there are no differences in the efficiency of anesthesia and PBF reduction between maxillary infiltrations at the two injection sites. One hundred twenty patients were divided into three groups according to the degree of carious lesion of their maxillary left central incisors (moderate caries, deep caries, or no caries). Forty patients in each group randomly received infiltrations over the root apex of maxillary left central incisors (site X) or over the midpoint of the line connecting the root apexes of both maxillary left central and lateral incisors (site Y) using 0.9 mL 2% lidocaine with 1:100,000 adrenaline. Teeth were pulp tested at five-minute intervals after injection except for the period of cavity cutting, which was done 12 minutes after injection. The PBF changes after injection were monitored by laser Doppler flowmetry. The observation period in this study was 60 minutes. Success of anesthesia was defined as no or mild pain on cavity cutting by visual analog scale recordings. Deep caries group showed significantly higher baseline PBF ( p<0.05). All groups showed 100% success of anesthesia and similar duration time ( p>0.05). Subgroups that had the injection at site Y showed significantly less reduction of PBF ( p<0.05). Cavity-cutting procedures increased the amplitude of the PBF around the lowest value after injection. Independent of the cavity depth, carious anterior teeth anesthetized by infiltration further from the apex had significantly less reduction on the pulpal blood flow compared with teeth anesthetized by infiltration at the apex.

Performance of Universal Adhesive in Primary Molars After Selective Removal of Carious Tissue: An 18-Month Randomized Clinical Trial

PURPOSE

To evaluate the 18-month clinical performance of a universal adhesive, applied under different adhesion strategies, after selective carious tissue removal in primary molars.

METHODS

Forty-four subjects (five to 10 years old) contributed with 90 primary molars presenting moderately deep dentin carious lesions on occlusal or occluso-proximal surfaces, which were randomly assigned following either self-etch or etch-and-rinse protocol of Scotchbond Universal Adhesive (3M ESPE). Resin composite was incrementally inserted for all restorations. Restorations were evaluated at one, six, 12, and 18 months using the modified United States Public Health Service criteria. Survival estimates for restorations' longevity were evaluated using the Kaplan-Meier method. Multivariate Cox regression analysis with shared frailty to assess the factors associated with failures (P<0.05).

RESULTS

Estimated survival rates of the restorations were 100 percent, 100 percent, 90.6 percent, and 81.4 percent at one, six, 12, and 18 months, respectively. The adhesion strategy did not influence the restorations' longevity (P=0.06; 72.2 percent and 89.7 percent with etch-and-rinse and self-etch mode, respectively).

CONCLUSION

Self-etch and etch-and-rinse strategies did not influence the clinical behavior of universal adhesive used in primary molars after selective carious tissue removal; although there was a tendency for better outcome of the self-etch strategy.

Partial Pulpotomy in Immature Permanent Molars After Carious Exposures Using Different Hemorrhage Control and Capping Materials

PURPOSE

This study compared the outcome of partial pulpotomies with mineral trioxide aggregate (MTA) or calcium hydroxide (CH) following hemorrhage control with 2.5 percent sodium hypochlorite (SH) or 0.9 percent sterile saline (SS) solutions in cariously exposed immature permanent molars.

METHODS

Following removal of two to three mm of the pulp at the exposure site, 80 Class I cavities were randomly allocated to four groups according to the hemorrhage control agent and pulp-capping material used: (1) group one-SH plus MTA; (2) group two-SS plus MTA; (3) group three-SH plus CH; (4) group four-SS plus CH. Glass ionomer cement was applied over the pulp-capping material, and the teeth were later restored with composite resin. The patients were recalled at six, 12, 18, and 24 months.

RESULTS

After 24 months, simultaneous radiographic and clinical success rates were 94.4 percent, 100 percent, 95 percent, and 100 percent for groups one to four, respectively (P>.05). No significant correlation was found between marginal integrity scores of restorations and partial pulpotomy failure (P>.05).

CONCLUSIONS

Partial pulpotomy, performed with MTA or CH used as the pulp-capping material following hemostasis with SH or SS solutions, provided comparable and favorable outcomes in carious pulp exposures of immature permanent teeth.

Randomized Clinical Trial to Evaluate MTA Indirect Pulp Capping in Deep Caries Lesions After 24-Months

OBJECTIVE

This clinical study aimed to assess the efficacies of mineral trioxide aggregate (MTA) and calcium hydroxide [Ca(OH)₂] in the treatment of deep carious lesions by the direct complete caries removal technique.

METHODS AND MATERIALS

A total of 100 permanent molar/premolar teeth were capped with either Ca(OH)₂ (n=49) or MTA (n=51) and restored with composite resin in 73 patients. Periapical radiographs were acquired prior to the treatment as well as at six, 12, and 24 months posttreatment. Two calibrated examiners performed the clinical and radiographic assessment of the periapical pathology and pulpal symptoms. Intergroup comparisons of the observed values were performed using the Fisher exact test. Significance was predetermined at α = 0.05.

RESULTS

The recall rates were 100% at six and 12 months posttreatment and 98.6% at 24 months posttreatment. Four teeth capped with Ca(OH)₂ (two each at six and 12 months posttreatment) and two capped with MTA (one each at 12 and 24 months posttreatment) received endodontic emergency treatment because of symptoms of irreversible pulpitis, which were clinically and/or radiographically established. There were no significant differences in pulp vitality between the two pulp-capping agents at six, 12, or 24 months posttreatment (p=0.238, p=0.606, and p=0.427, respectively).

CONCLUSIONS

Both pulp-capping materials were found to be clinically acceptable at 24 months posttreatment.

Improvised Vacuum-Assisted Closure for severe neck infection in poorly equipped conditions

INTRODUCTION

Dental infections are common and are mainly due to dental caries. When left untreated, these infections can lead to severe life-threatening sepsis.

CASE REPORT

The authors reported a case of a severe odontogenic deep neck space infection in a 54-year-old male. The patient was a heavy smoker with incidentally discovered diabetes. He was successfully treated by surgical drainage combined with an improvised Vacuum-Assisted Closure (VAC) system. The results of surgical drainage followed by insertion of an improvised VAC system were spectacular. The abscess resolved in response to dual-agent antibiotic therapy on day 17 and blood glucose control was achieved with insulin. Full-thickness skin graft was performed to repair the necrotic zone of the neck.

DISCUSSION

The use of VAC can be a valuable alternative to conventional dressings and hyperbaric oxygen therapy in poorly equipped conditions. Public awareness campaigns remain the most effective form of prevention against these odontogenic infections.

Restorative Treatment Decisions in Posterior Teeth: A Systematic Review

PURPOSE

To determine the stage of caries in posterior permanent teeth at which dentists decide to intervene invasively.

MATERIALS AND METHODS

A search of the literature from January 1980 to November 2015 available in MEDLINE-PubMed, EMBASE, and the Cochrane Library was conducted. The main search terms used were decision-making, restorative treatment, dental caries lesion, occlusal surface, and approximal surface. The inclusion criterion was studies including dentists only. Three reviewers independently screened titles and abstracts to determine the eligibility of studies. Subsequently, the full texts of the papers deemed eligible were perused and included in the data extraction process.

RESULTS

The review encompassed 11 studies and the methodological quality was considered moderate. Most dentists would restore lesions confined to enamel and reaching the outer half of the dentin, irrespective of the surface involved. With regard to the occlusal surface, the percentage of dentists who restored enamel lesions ranged from 4.6% to 17.8%. Regarding dentin lesions (outer half), 50.2%-70.2% of the dentists opted for invasive treatment. For the approximal surface, the choice for invasive treatment of enamel lesions ranged from 5%-88%. In dentin lesions, 4.4%-94% of dentists restored lesions in the outer half of the dentin.

CONCLUSION

Despite the progress achieved in the understanding of the development and management of caries, dentists still recommend restorative treatment in its early stages.

A retrospective investigation of the oral health records of a cohort of preschool children who received extractions under general anaesthesia including cost analysis of treatment

Internationally, a considerable proportion of children aged five years and younger require extraction of teeth due to dental caries and frequently dental general anaesthesia (DGA) is the treatment of choice.

AIMS

To investigate the records of a cohort of preschool children (aged five years and younger) referred to the public dental service provided at Cork University Hospital (CUH), Cork, Ireland, for extractions under DGA between the years 2000 and 2002. To determine the characteristics of the sample: disadvantage; the presence of a significant medical history; and, fluoride status. To establish the pattern of appointments and care, before, during and after DGA, and the pattern of dental treatment required up to sixth class (aged 11 to 12 years).

METHODS

A retrospective review of dental records of a cohort of preschool-aged children referred for DGA in CUH during the years 2000-2002 was completed. Demographic and clinical data were collated and analysed using Statistical Packages for Social Sciences (SPSS). Costs were provided by CUH and the Health Service Executive (HSE). Data on costs relating to preventive programmes were obtained from information presented in the Irish Oral Health Services Guideline Initiative 2009.

RESULTS

A total of 347 children were included with a median age of.fQur years and a range of one to five years. Children with a disadvantage were more likely to require extractions under DGA than their- counterparts (50%, n=175). In total, 73% (n=253)~ of patients had a fluoridated water supply and 91% (n=316) had no adverse medical history. For 88% (n=306), their first dental visit was an emergency appointment. The primary indication for DGA was treatment of dental caries. A recall appointment was provided for 18% (n=63). One-quarter (n=86) required an extraction, antibiotic or referral for a second DGA at their first visit following DGA. In first class, referral for a second DGA or extraction under local anaesthetic (LA) was required for 23% (n=79) of patients. Over 60% (n=21 1) required either an extraction or a restoration in third class. In excess of 20% (n=69) of patients did not attend the sixth class dental inspection, the final assessment appointment in the public services.

CONCLUSIONS

A considerable number of preschool children require extractions under DGA due to dental caries. The results of this study indicate that such children progress to adolescence with poor oral health, as evidenced by the need for further restorations, extractions and repeat DGA. The average cost of DGA was E819 per child. This figure has been shown to be as much as eight times the cost of a preventive/oral health promotion prograrnme operating within a similar cohort. An integrated preventive programme targeting preschool-aged children should be considered in attempting to manage the hicih levels of dental caries within this age group.

In Vivo Effect of Calcium Hydroxide and Resin-modified Glass Ionomer Cement on Carious Dentin in Young Permanent Molars: An Ultrastructural and Macroscopic Study

PURPOSE

The purpose of this study was to evaluate macroscopically and ultrastructurally the effect of calcium hydroxide cement (CH) and resin-modified glass ionomer cement (RMGIC) compared with gutta percha (control) as a lining material on carious dentin after partial caries removal and sealing.

METHODS

Twenty-seven permanent molars with deep carious lesions underwent partial caries removal with the application of CH, RMGIC, or gutta percha (control) and were then sealed for three months. After a partial caries removal and sealing period, the dentin was macroscopically assessed (for color, consistency, and humidity) and further analyzed by scanning electron microscope to assess the ultrastructural changes in dentin (lumen size, mineralization of tubules, occlusion of tubules by cements, and bacterial ingress). The effect of treatment in each group was statistically analyzed.

RESULTS

Dentin darkening and hardening were observed after the sealing period in all groups. However, there was no difference in the color after treatment among the three groups. It was observed that RMGIC showed a significant reduction in the size of the lumen compared to CH and the control.

CONCLUSION

Partial caries removal and sealing resulted in dentin hardening, darkening, and dentin remineralization, irrespective of the dentin protection used.

Endodontic treatment

The Finnish guideline on endodontics emphasizes good quality of endodontic treatment and coronal seal of the restoration. For prevention of endodontic treatment need caries control is essential. For deep carious lesions stepwise excavation or partial caries removal are recommended. Partial pulpotomy can be used if bleeding can be controlled. The decision for root canal treatment is based on prognosis, occlusion and general health of the patient. The use of kofferdam is essential in aseptic working. Chemomechanical preparation with NaOCI and root canal filling within 0-2 mm from the apex improve prognosis. Healing should be controlled annually up to four years.

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.

Caries Removal by First-Year Dental Students: A Multisource Competency Assessment Strategy for Reflective Practice

Multisource assessment (MSA) uses multiple assessors to provide feedback. Little is known about the validity of using MSA feedback for improving students' ability to self-assess in a preclinical environment. Therefore, the aim of this study was to measure the validity of using a defined reflective process involving an MSA tool for building skill in dental students' self-evaluation of caries excavation on extracted teeth. As part of this process, 104 first-year students at one U.S. dental school used a self-generated study plan (SGSP) for structured reflection on MSA feedback during the 2013-14 academic year. Interrater agreement, determined through calculation of percentage-agreements in scoring, was measured among three assessor groups (self-, peer, and expert assessors) in formative assessment and between two assessor groups (self- and expert assessors) in summative assessment two weeks apart, allowing for reflective practice and completion of an SGSP between assessments. Validity for improving self-assessment was determined by measuring significance in positive shifts of agreement between self- and expert assessors. The results showed that interrater agreement between the self- and expert assessors increased significantly: from a 28% agreement in formative assessment to a 60% agreement in summative assessment. Significance in percentage shifts between assessments was demonstrated with a McNemar score of 0.26 (p<0.001). These results suggest that the described MSA tool and reflective process in an SGSP may be valid methods for improving skill in student self-evaluation of competence in caries excavation on extracted teeth.

Dental care in patients with antiphospholipid syndrome: two case reports

Antiphospholipid syndrome (APS) is a prothrombotic autoimmune disease that may be classified as primary or secondary. Treatment consists of oral anticoagulant, antiplatelet, and/or immunosuppressant drugs. This report describes the dental treatment of 2 women with APS and multiple dental concerns, including periodontal disease, caries, and missing teeth. The invasive dental procedures were performed in an outpatient setting with hematologic monitoring and use of local hemostatic measures. Neither interruption of anticoagulant medications nor administration of blood products was necessary. All of the procedures were performed without complications. To date, no recommendations for the dental care of patients with APS have been established, demonstrating a need to investigate the risks for bleeding and infection, among other concerns, during dental treatment of these patients.

Remote Dental Surgery as a Medical Civilian Assistance Program (MEDCAP): Helping Iraqi, Kurdish, and U.S. Forces Win Hearts and Minds in the Fight Against Daesh

Dr Ferreira discusses the work of the Humanitarian Aid and Security Forces (HASF) in providing volunteer dental services to a local Christian militia in Mosul, Iraq.

Carious Exposure versus Mechanical Exposure for MTA Pulpotomy in Primary Teeth

Introduction. The etiology of exposure determines pulpal response, making it crucial to distinguish between mechanical and carious exposure. This study clinically and radiographically evaluated the success of MTA pulpotomies conducted to treat carious and mechanical pulp exposure. Materials and Methods. This study was conducted with 50 mandibular primary molar teeth. Teeth were divided into 2 groups according to status of the exposure site, with teeth surrounded by carious dentin placed in a carious exposure group and those surrounded by sound dentin in a mechanical exposure group. MTA pulpotomies were performed for both groups. Treatment was followed up clinically and radiographically for 18 months. Results. Clinical and radiographic success rates at 18 months were 100% for both groups. Success rates did not vary significantly between the groups (p = 1.000). Pulp canal obliteration was only seen in the carious exposure group, observed in 2 teeth (8.3%). Conclusion. The long term success rates achieved in this study indicate that MTA can be used as a vital pulpotomy material for the long term success in primary teeth with either mechanical or carious exposure. The findings of the present study highlight the fact that treatment prognosis is dependent upon diagnosis and selection of the appropriate materials for treatment.

Dental cavity liners for Class I and Class II resin-based composite restorations

BACKGROUND

Resin-based composite (RBC) is currently accepted as a viable material for the restoration of caries for posterior permanent teeth requiring surgical treatment. Despite the fact that the thermal conductivity of the RBC restorative material closely approximates that of natural tooth structure, postoperative hypersensitivity is sometimes still an issue. Dental cavity liners have historically been used to protect the pulp from the toxic effects of some dental restorative materials and to prevent the pain of thermal conductivity by placing an insulating layer between restorative material and the remaining tooth structure.

OBJECTIVES

The objective of this review was to assess the effects of using dental cavity liners in the placement of Class I and Class II resin-based composite posterior restorations in permanent teeth in children and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library (searched 25 May 2016), MEDLINE Ovid (1946 to 25 May 2016), Embase Ovid (1980 to 25 May 2016) and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 25 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomized controlled trials assessing the effects of the use of liners under Class I and Class II posterior resin-based composite restorations in permanent teeth (in both adults and children). We included both parallel and split-mouth designs.

DATA COLLECTION AND ANALYSIS

We utilized standard methodological procedures prescribed by Cochrane for data collection and analysis. Two review authors screened the search results and assessed the eligibility of studies for inclusion against the review inclusion criteria. We conducted risk of bias assessments and data extraction independently and in duplicate. Where information was unclear we contacted study authors for clarification.

MAIN RESULTS

Eight studies, recruiting over 700 participants, compared the use of dental cavity liners to no liners for Class I and Class II resin-based composite restorations.Seven studies evaluated postoperative hypersensitivity measured by various methods. All studies were at unclear or high risk of bias. There was inconsistent evidence regarding postoperative hypersensitivity (either measured using cold response or patient-reported), with a benefit shown at some, but not all, time points (low-quality evidence).Four trials measured restoration longevity. Two of the studies were judged to be at high risk and two at unclear risk of bias. No difference in restoration failure rates were shown at one year follow-up, with no failures reported in either group for three of the four studies; the fourth study had a risk ratio (RR) 1.00 (95% confidence interval (CI) 0.07 to 15.00) (low-quality evidence). Three studies evaluated restoration longevity at two years follow-up and, again, no failures were shown in either group.No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

There is inconsistent, low-quality evidence regarding the difference in postoperative hypersensitivity subsequent to placing a dental cavity liner under Class I and Class II posterior resin-based composite restorations in permanent posterior teeth in adults or children 15 years or older. Furthermore, no evidence was found to demonstrate a difference in the longevity of restorations placed with or without dental cavity liners.

Three-Year Clinical Evaluation of Class I Restorations in Posterior Teeth. Effects of Two Adhesive Systems

This longitudinal study evaluated the clinical performance of 97 direct class I resin composite restorations after 3 years. The restorations were performed using 2 types of adhesive systems: (1) Adper™ Single Bond Plus (SB) (3M ESPE, 3mespe.com), which is a two-step etch-and-rinse system, and (2) Adper Scotchbond™ SE (SE) (3M ESPE), which is a two-step self-etching system. Two calibrated examiners evaluated the restorations using modified US Public Health Service criteria. The materials were applied following the manufacturer's instructions, and 15 patients received at least one of the two adhesive systems. The restorations were evaluated 7 days after placement (baseline) and again after 3 years. Statistical analysis was performed using a proportion t-test at a significance level of 5% (P < .05). At baseline, all restorations received an Alpha score for the variable marginal discoloration and marginal integrity. After 3 years, marginal discoloration received an Alpha score for 53.19% of the restorations performed with SB and 52.08% with SE. Marginal integrity was rated as Alpha for 65.96% and 68.75% of the restorations with SB and SE systems, respectively. The remaining restorations received Bravo scores for all variables. Eight restored teeth presented postoperative sensitivity at baseline (5 SB; 3 SE), but no sensitivity was found after 3 years. No secondary caries was verified. No statistically significant differences were observed between the teeth restored with the SB and SE systems for marginal discoloration (P = .7880) and marginal integrity (P = .8132) after 3 years. Direct class I resin composite restorations performed with a two-step etch-and-rinse and a two-step self-etching adhesive system demonstrated satisfactory clinical performance after 3 years.

An evidence-based review of dental matrix systems

The restoration of proximal surface cavities, originating from Class II carious lesions, to "normal" anatomical specifications is a fundamental objective for the dental practitioner. Cognitive interpretation of tooth morphology attained from evidence-based resources, together with the necessary psychomotor skills for correct design and completion, are considered essential strategies for restoration success. Also, the visualization of the original tooth structure, if present, should substantially benefit the dentist in the creation of a clinically satisfactory restoration. The purpose of this evidence-based review is to define the cause and effect of decisions based on optimum treatment standards of care for the patient. The concepts of form and function, as related to the oral environment, and the consequences of unsatisfactory dental restorative care will be scrutinized. This article will identify and explain the different challenges and solutions for restoration of dental proximal lesions and provide an overview of past, present, and future procedures.

Zirconia-Prefabricated Crowns for Pediatric Patients With Primary Dentition: Technique and Cementation for Esthetic Outcomes

Traditionally, many clinicians tend to forego esthetic considerations when full-coverage restorations are indicated for pediatric patients with primary dentitions. However, the availability of new zirconia pediatric crowns and reliable techniques for cementation makes esthetic outcomes practical and consistent when restoring primary dentition. Two cases are described: a 3-year-old boy who presented with severe early childhood caries affecting both anterior and posterior teeth, and a 6-year-old boy who presented with extensive caries of his primary posterior dentition, including a molar requiring full coverage. The parents of both boys were concerned about esthetics, and the extent of decay indicated the need for full-coverage restorations. This led to the boys receiving treatment using a restorative procedure in which the carious teeth were prepared for and restored with esthetic tooth-colored zirconia crowns. In both cases, comfortable function and pleasing esthetics were achieved.