Complete or ultraconservative removal of decayed tissue in unfilled teeth

The scientific management of deep carious lesions in vital teeth using contemporary materials—A narrative review

Aim

The aim of this article is to review the scientific evidence for deep caries removal in permanent vital teeth and the choice of dentine replacement material and restoration of the teeth to maintain long term tooth vitality and function.

Method

The two position statements namely the European Society of Endodontology and the American Association of Endodontists position statements on vital pulp therapy will be scrutinized and compared with regards to the deep caries removal strategy and assessed for evidence of best practice. The properties of materials used to manage vital pulps and the best way to restore the teeth will be reviewed and guidance on the full management of vital teeth will be suggested.

Conclusions

Promoting new treatment modalities for reversible and irreversible pulpitis allowing for pulp preservation should be considered. Although debatable, cases with deep caries should be managed by complete non-selective caries removal which will allow for pulpal management if needed and a more predictable outcome can be expected when using the new materials and treatment modalities of vital pulp therapy.

Application of Selected Biomaterials and Stem Cells in the Regeneration of Hard Dental Tissue in Paediatric Dentistry-Based on the Current Literature

Currently, the development of the use of biomaterials and their application in medicine is causing rapid changes in the fields of regenerative dentistry. Each year, new research studies allow for the discovery of additional possibilities of dental tissue restoration. The structure and functions of teeth are complex. They consist of several diverse tissues that need to act together to ensure the tooth’s function and durability. The integrity of a tooth’s enamel, dentin, cementum, and pulp tissue allows for successful mastication. Biomaterials that are needed in dentistry must withstand excessive loading forces, be biocompatible with the hosts’ tissues, and stable in the oral cavity environment. Moreover, each tooth’s tissue, as well as aesthetic qualities in most cases, should closely resemble the natural dental tissues. This is why tissue regeneration in dentistry is such a challenge. This scientific research focuses on paediatric dentistry, its classification of caries, and the use of biomaterials in rebuilding hard dental tissues. There are several methods described in the study, including classical conservative methods such as caries infiltration or stainless-steel crowns. Several clinical cases are present, allowing a reader to better understand the described methods. Although the biomaterials mentioned in this work are artificial, there is currently ongoing research regarding clinical stem cell applications, which have a high potential for becoming one of the most common techniques of lost dental-tissue regeneration in the near future. The current state of stem cell development is mentioned, as well as the various methods of its possible application in dentistry.

Treatment of symptomatic, deep, almost cariously exposed lesions using ozone

The aim of this controlled randomized crossover study was to assess post-treatment pain and the need for root canal treatment after the use of a traditional caries removal method followed by restoration, or after an ozone method of more conservatively managing the deep caries and a restoration. 84 participants (42 males and 42 females, mean age ± SD = 23.9 ± 2.0 years) were randomly allocated to receive either a traditional (n = 42, 21 males and 21 females) or ozone (n = 42, 21 males and 21 females) method. The ozone method only differed from the traditional method by leaving the deep leathery caries on the pulpal floor and then treating this with 20 s of ozone from the healozone X4 (Curozone, Germany). All caries was removed in the traditional group. A conventional glass ionomer cement (Riva Self Cure High Viscosity, SDI, Australia) was placed followed by a bonded composite resin restoration (Filtek Z250 Universal Restorative, 3 M ESPE, USA) in each cavity. The visual analogue scale was used to assess pain scores before treatment and after 24 h. The participants were then followed up for 2 years to assess the need for root canal treatment. Statistical significance levels were set at α ≤ .05. Both groups were associated with significant reduction of pain scores 24 h after treatment (p < .0001). The ozone treatment was associated with less pain 24 h after treatment (p < .0001) and less need for root canal treatment (p = .014), after 2 years follow up, than the conventional treatment. In conclusion, treatment of symptomatic, deep carious lesions by ozone following partial removal of caries was accompanied with less pain and occurrence of RCT after treatment compared to traditional complete caries removal.

Conceptual Model for Using Imidazoline Derivative Solutions in Pulpal Management

Alpha-adrenergic agonists, such as the Imidazoline derivatives (ImDs) of oxymetazoline and xylometazoline, are highly effective hemostatic agents. ImDs have not been widely used in dentistry but their use in medicine, specifically in ophthalmology and otolaryngology, warrants consideration for pulpal hemostasis. This review presents dental healthcare professionals with an overview of ImDs in medicine. ImD solutions have the potential to be more effective and biocompatible than existing topical hemostatic compounds in pulpal management. Through a comprehensive analysis of the pharmacology of ImDs and the microphysiology of hemostasis regulation in oral tissues, a conceptual model of pulpal management by ImD solutions is presented.

The effect of selective carious tissue removal and cavity treatments on the residual intratubular bacteria in coronal dentine

Background/purpose

The use of cavity treatments may help in the reduction of bacteria remaining in dentinal tubules after selective carious tissue removal. This study aimed to investigate the effect of selective carious tissue removal and treatment with either 35% phosphoric acid +0.12% chlorhexidine or dentine conditioner on the residual intratubular bacteria in coronal dentine of deep carious lesions.

Materials and methods

Thirty carious human molars were randomly divided into three groups; group 1: untreated carious teeth (positive control), group 2: carious teeth treated with 35% phosphoric acid and chlorhexidine disinfectant after selective carious tissue removal and group 3: carious teeth treated with dentine conditioner after selective carious tissue removal. Another six non-carious teeth was used as negative control. The presence of bacteria and depth of bacteria remaining in dentinal tubules were determined by scanning electron microscopy (SEM). Chi square test and one-way, repeated-measures analysis of variance were used for statistical analysis.

Results

Using SEM, coronal dentine of group 1, 2 and 3 revealed cocci, rod and filamentous bacteria within dentinal tubules. Positive rates of bacteria detection in coronal dentine of group 1 were significant higher than those of group 2 and 3 (P < 0.05). The distance of bacteria remaining in the dentinal tubules in group 1, 2 and 3 were 1149.14 ± 384.44, 707.98 ± 357.19 and 869.25 ± 470.75 μm, respectively.

Conclusion

Both treatment groups had similar ability to reduce the number of intratubular bacteria in coronal dentine of carious teeth, but not complete elimination.

Preserving pulp vitality: part one - strategies for managing deep caries in permanent teeth

This is the first article in a series reviewing the current literature surrounding the management of deep caries in permanent teeth. Approaches to caries management are continuing to evolve, with more conservative management increasingly favoured. This philosophy has never been more important than in managing the deep carious lesion. Evidence is emerging that the use of selective caries removal to reduce the risk of pulp exposure, in conjunction with calcium silicate cements, can be successful in maintaining pulp vitality, delaying the restorative cycle and prolonging the lifespan of the tooth.

Is Fluorescence Technology a Promising Tool for Detecting Infected Dentin in Deep Carious Lesions?

The purpose of this study was to determine if the degree of fluorescence detected by fluorescence-aided caries excavation (FACE) correlates with dentin bacterial microbiome diversity, as assessed by 16S rRNA gene amplicon sequencing, and with traditional tactile dentin caries assessment. Unidentified human teeth were obtained from a dental facility. The included teeth had a carious lesion two-thirds into the dentin, verified by radiography, and were red-fluorescing (RF) using FACE technology (SIROInspect; Sirona, Bensheim, Germany). Two independent examiners performed visual/tactile assessment of the lesions. RF sites were sampled with a sterile spoon excavator and dentin characteristics were evaluated. Once RF dentin was removed, a second sample of pink-fluorescing (PF) dentin was obtained. After excavation with a sterile round bur to nonfluorescing (NF) dentin, a third sample was collected with a slow-speed round bur. The samples were processed at the UNC (University of North Carolina at Chapel Hill) Microbiome Core Facility. Out of 134 extracted teeth collected, 21 fit the inclusion criteria, yielding 61 dentin samples. RF samples had the highest number of observed operational taxonomic units (n = 154), followed by PF (n = 109) and NF (n = 100). RF carious dentin was primarily "soft," and NF dentin was assessed as "hard" 100% of the time by both examiners (rank correlation χ2: p < 0.001). However, approximately one-third of the tactile assessments of hard dentin still displayed some fluorescence, either pink or red. We concluded that the sampled fluorescing (RF and PF) and NF carious dentin layers displayed diverse bacterial taxa, and tactile assessments of soft, leathery, and hard corresponded with RF, PF, and NF.

Influence of ozone application in the stepwise excavation of primary molars: a randomized clinical trial

OBJECTIVES

The aim of this randomized, controlled, three-arm parallel-group, double-blinded clinical trial was to investigate the clinical and microbiological effects of the ozone application in stepwise excavation of primary molars.

MATERIALS AND METHODS

This study was conducted in in vivo conditions with 105 lower primary molars that had deep caries lesions. The teeth were randomly divided into three groups: (I) control group, conventional stepwise excavation with no disinfectants; (II) CHX (positive control) group, 2% chlorhexidine digluconate; and (III) experimental group, ozone application. Dentine samples were collected at 4 different time points (T0, at the first appointment, after partial removal of carious dentin; T1, at the first appointment, after applying disinfection procedure; T2, at the second appointment - at the end of the 4-month period - immediately after the removal of the temporary restoration; T3, at the second appointment, after the final excavation) for the microbiological analysis of mutans streptococci and lactobacilli and the total number of colony-forming units. Clinical changes including dentin color, humidity, and consistency were recorded. Data were analyzed using the Mann-Whitney U test, Friedman test, and chi-squared test (p = 0.05).

RESULTS

The dentin became harder and drier after 4 months in all the groups. There was a gradual reduction in the total number of microorganisms in all the three groups. Bacterial reduction was greater in the CHX group compared to the ozone group (p = 0.002) and was greater in the ozone group compared to the control group (p = 0.015) after 4 months (control, 78%; CHX, 93%; ozone, 82%).

CONCLUSION

Stepwise excavation of primary teeth provided successful outcomes in all the groups. Moreover, CHX, due to its practicality and cost-effectiveness, can be effectively used with one- or two-step indirect pulp therapies.

CLINICAL RELEVANCE

Usage of cavity disinfectants in the stepwise excavation procedure contributes to the reduction of bacterial population in the cavity, which may allow the avoidance of the second step of the indirect pulp therapy for primary teeth.

Comparative Evaluation of the Efficacy of Stepwise Caries Excavation vs Indirect Pulp Capping in Preserving the Vitality of Deep Carious Lesions in Permanent Teeth of Pediatric Patients: An In Vivo Study

Aims and objectives

To comparatively evaluate the clinical efficacy of stepwise caries excavation with indirect pulp capping (IPC) in managing the young permanent teeth in pediatric patients who have deep carious lesions.

Materials and methods

Eighty-eight teeth (first/second permanent molars) were included and randomly divided into two groups: group I (stepwise caries excavation) and group II (IPC). For group I, i.e., stepwise caries excavation, in the initial visit, bulk caries removal was done from walls of the cavity, however, soft and infected dentin was left untouched on the pulpal floor. The final excavation was performed after 2 months. The dentin parameters like the color, the consistency, and the humidity of dentin were noted at the first and second visits. A final follow-up to assess the primary outcome, i.e., sustained pulp vitality, was done after 1 year.

Results

When both the groups were compared with each other using the Chi-squared test, a highly significant difference was found (p < 0.05) between them. The success rate of stepwise caries excavation (97.3%) was found to be significantly greater than IPC (82.4%). After doing statistical analysis, a significant difference between stepwise excavation at baseline and at re-entry for parameters like the color, the consistency, and the humidity (p < 0.05), where dentin was observed to be darker in color, harder in consistency, and drier to touch at re-entry was found.

Conclusion

Stepwise caries excavation was considered a safer technique than IPC for preserving the vitality of young permanent teeth. Also, the clinical changes recorded during the re-entry in the case of stepwise caries excavation technique indicated the arrest of the carious process.

Clinical significance

Pulp preservation is of utmost importance especially in the case of young permanent teeth which have open apex to aid in apexogenesis. Failure to do so in maintaining the vitality of pulp before root completion may lead to the unfavorable crown to root ratio resulting in thin dentinal walls which are prone to fracture.

How to cite this article

Manhas S, Pandit IK, Gugnani N, et al. Comparative Evaluation of the Efficacy of Stepwise Caries Excavation vs Indirect Pulp Capping in Preserving the Vitality of Deep Carious Lesions in Permanent Teeth of Pediatric Patients: An In Vivo Study. Int J Clin Pediatr Dent 2020;13(S-1):S92–S97.

Surgical Management of Caries Lesions: Selective Removal of Carious Tissues

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

WITHDRAWN: Operative caries management in adults and children

BACKGROUND

The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 12 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 12 December 2012) and EMBASE via OVID (1980 to 12 December 2012). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Parallel group and split-mouth randomised and quasi-randomised controlled trials comparing stepwise, partial or no dentinal caries removal with complete caries removal, in unrestored primary and permanent teeth were included.

DATA COLLECTION AND ANALYSIS

Three review authors extracted data independently and in triplicate and assessed risk of bias. Trial authors were contacted where possible for information. We used standard methodological procedures exacted by The Cochrane Collaboration.

MAIN RESULTS

In this updated review, four new trials were included bringing the total to eight trials with 934 participants and 1372 teeth. There were three comparisons: stepwise caries removal compared to complete one stage caries removal (four trials); partial caries removal compared to complete caries removal (three trials) and no dentinal caries removal compared to complete caries removal (two trials). (One three-arm trial compared complete caries removal to both stepwise and partial caries removal.) Four studies investigated primary teeth, three permanent teeth and one included both. All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I2 = 0%) compared to complete caries removal based on moderate quality evidence, with no heterogeneity. In these four studies, the mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I2 = 0%).Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I2 = 0%), also based on moderate quality evidence with no evidence of heterogeneity. In these two studies the mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I2 = 0%, low quality evidence), or restoration failure (one study showing no difference and another study showing no failures in either group, very low quality evidence).No dentinal caries removal was compared to complete caries removal in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies.

AUTHORS' CONCLUSIONS

Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

Effectiveness of the ozone application in two-visit indirect pulp therapy of permanent molars with deep carious lesion: a randomized clinical trial

OBJECTIVES

The aim of this randomized, three-arm parallel, single-blinded clinical trial was to evaluate the clinical and microbiological effectiveness of the ozone application in two-visit indirect pulp therapy.

MATERIALS AND METHODS

One hundred five lower first molar teeth with deep caries lesion were included and randomly assigned three groups to apply the two-visit indirect pulp therapy. Treatment procedure was applied without any disinfectant (control), with 60-s 2% chlorhexidine digluconate (CHX) or 60-s ozone application. In four different stages (after initial excavation, ozone/CHX application before the temporary restoration, 4 months later immediately after removing temporary restoration, and final excavation), dentin humidity, consistency, and color properties were recorded to evaluate the clinical characteristics of the tissue, and standard dentin samples were collected for the microbiological analysis of mutans streptococci, lactobacilli, and the total number of colony-forming units. The data were analyzed by using Mann-Whitney U test for multiple comparisons.

RESULTS

The remaining dentin became harder, drier, and darker after 4 months in all groups. However, CHX and ozone application were statistically better than the control group (p < 0.05). There was a gradual decrease in the total number of microorganisms in all groups. While cavity disinfectant applications were improved the antibacterial efficacy (control, 79.11%; CHX, 98.39%; ozone, 93.33%), CHX application exhibited a greater significant reduction than both groups (p = 0.000).

CONCLUSION

The two-visit indirect pulp therapy yielded successful results for all study groups. However, CHX would be conveniently preferable due to improving the treatment success.

CLINICAL RELEVANCE

The two-visit indirect pulp therapy applied with cavity disinfectant is a proper alternative treatment procedure in deep carious lesions, instead of conventional technique.

Management preferences of deep caries in permanent teeth among dentists in Saudi Arabia

Objective:

To report the management preferences of deep caries in permanent teeth among dentists.

Materials and Methods:

This observational cross-sectional study included a convenience sample of 177 dentists selected from private and public dental clinics in different cities of the Eastern Province of Saudi Arabia. Four clinical scenarios about the absence or presence of pain/symptoms and the risk of pulp exposure in deep caries were presented to the dentists in a pilot-tested questionnaire.

Results:

Most dentists (82.5%) preferred complete caries excavation when there was no risk of pulp exposure and no pain/symptom was associated with deep caries in permanent teeth. The stepwise technique was the procedure of choice reported by 57.8% of dentists when there was no pain but a risk of exposure was present. In case of no exposure risk but the presence of nonspontaneous pain (pain on thermal testing), complete caries removal was chosen by 55.9% of the respondents. Root canal treatment and stepwise caries removal were preferred by 42.4% and 38.4%, respectively, when there was a risk of exposure and nonspontaneous pain. The risk of exposure (81.4%), the progression of caries (73.4%), and treatment failure (58.8%) were the most common concerns with different caries removal techniques. The hardness was the most commonly used criterion (85.3%) followed by the color of caries (50.3%) during caries excavation.

Conclusions:

The majority of dentists preferred to completely remove caries in case of no risk of pulp exposure. The dentists should update their knowledge and adopt latest concepts about minimally invasive caries removal approaches.

Evaluation of Dentin-Pulp Complex Response after Conservative Clinical Procedures in Primary Teeth

Introduction

Although selective caries tissue removal decreases the number and diversity of bacteria, stops the caries process, and reduces the risk of pulp exposure, the studies on the minimally removal of caries tissue are limited and further clinical research is necessary in this field.

Aim

This study aimed to evaluate through clinical and radiographic assessments the in vivo response of the dentin-pulp complex of human deciduous teeth after either partial or total caries removal (TCR).

Materials and methods

A total of 49 deciduous molars of children aged between 5 and 9 years were carefully selected. The teeth were divided into two groups: Group I: Partial removal of caries; group II: Total removal of caries. Clinical and radiographic evaluations were performed during the period of 4 to 6 months after the procedure. The intraexam-iner reproducibility was determined by Kappa test. Fisher’s exact test was used to determine the statistical difference between groups.

Results

All teeth showed clinical success during the 4- to 6-month evaluation period. The radiographic evaluation showed 94.2 and 89.6% of success rate in groups I and II respectively. Radiographic results did not show statistically significant differences between the studied groups (p > 0.05).

Conclusion

The partial caries removal (PCR) showed satisfactory clinical and radiographic outcomes, suggesting that this minimally invasive approach might replace the TCR when correctly indicated.

How to cite this article: Mello B, Stafuzza TC, Vitor L, Rios D, Silva T, Machado M, Oliveira TM. Evaluation of Dentin-Pulp Complex Response after Conservative Clinical Procedures in Primary Teeth. Int J Clin Pediatr Dent 2018;11(3):188-192.

Secondary Sjögren syndrome: A case report using silver diamine fluoride and glass ionomer cement

BACKGROUND AND OVERVIEW

The authors describe dental treatment for a patient with a complex medical history of secondary Sjögren syndrome with systemic lupus erythematosus and rheumatoid arthritis.

CASE DESCRIPTION

An 18-year-old woman's rheumatology group referred her for oral evaluation; she had secondary Sjögren syndrome, systemic lupus erythematosus, and rheumatoid arthritis. The patient had multiple advanced carious lesions, extreme sensitivity, and hyposalivation. The patient selected a minimally invasive treatment plan that focused on silver diamine fluoride (SDF), partial caries removal, and glass ionomer cement (GIC) restorations. The SDF treatment and GIC restorations were successful in arresting carious lesions and restoring form and function but may not completely prevent new carious lesions from forming in the future.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The case shows that using less invasive treatments, such as SDF and GIC restorations can be used to manage complex cases involving extreme caries risk and be preferable to endodontic treatment and extractions.

Doxycycline-containing glass ionomer cement for arresting residual caries: an in vitro study and a pilot trial

In a previous study, we demonstrated that the incorporation of doxycycline hyclate (DOX) into resin-modified glass ionomer cement (RMGIC) inhibited important cariogenic microorganisms, without modifying its biological and mechanical characteristics. In this study, we keep focused on the effect of that experimental material as a potential therapy for arresting residual caries by analyzing other in vitro properties and conducting a pilot clinical trial assessing the in vivo effect of DOX-containing RMGIC on residual mutans streptococci after partial carious removal in primary molars. Specimens of the groups RMGIC (control); RMGIC + 1.5% DOX; RMGIC + 3% DOX; and RMGIC + 4.5% DOX were made to evaluate the effect of DOX incorporation on surface microhardness and fluoride release of RMGIC and against biofilm of Streptococcus mutans. Clinical intervention consisted of partial caries removal comparing RMGIC and RMGIC + 4.5% DOX as lining materials. After 3 months, clinical and microbiologic evaluations were performed. Data were submitted to ANOVA/Tukey or Wilcoxon/Mann-Whitney set as α=0.05. Fluoride release and surface microhardness was not influenced by the incorporation of DOX (p>0.05). There was a significant reduction of S. mutans biofilm over the material surface with the increase of DOX concentration. After clinical trial, the remaining dentin was hard and dry. Additionally, mutans streptococci were completely eliminated after 3 months of treatment with RMGIC + 4.5% DOX. The incorporation of DOX provided better antibiofilm effect, without jeopardizing fluoride release and surface microhardness of RMGIC. This combination also improved the in vivo shortterm microbiological effect of RMGIC after partial caries removal.

Randomized Clinical Trials on Deep Carious Lesions: 5-Year Follow-up

Deep caries presents a dilemma in terms of which treatment that will render an optimal prognosis by maintaining pulp vitality with absence of apical pathology. Previously, 2 randomized clinical trials were performed testing the short-term effects of stepwise carious tissue removal versus nonselective carious removal to hard dentin with or without pulp exposure. The aim of this article was to report the 5-y outcome on these previously treated patients having radiographically well-defined carious lesions extending into the pulpal quarter of the dentin but with a well-defined radiodense zone between the carious lesion and the pulp. In this long-term study, 239 of 314 (76.2%) patients were analyzed. The stepwise removal group had a significantly higher proportion of success (60.2%) at 5-y follow-up compared with the nonselective carious removal to hard dentin group (46.3%) ( P = 0.031) when pulp exposures per se were included as failures. Pulp exposure rate was significantly lower in the stepwise carious removal group (21.2% vs. 35.5%; P = 0.014). Irrespective of pulp exposure status, the difference (13.3%) was still significant when sustained pulp vitality without apical radiolucency and unbearable pain was considered (95% confidence interval, 3.1-26.3, P = 0.045). After pulp exposure, only 9% ( n = 4) of the analyzed patients were assessed as successful, indicating that the prognosis is highly dubious following conventional pulp-capping procedures (direct pulp capping or partial pulpotomy) in deep carious lesions in adults. In conclusion, the stepwise carious removal group had a significantly higher proportion of pulps with sustained vitality without apical radiolucency versus nonselective carious removal of deep carious lesions in adult teeth at 5-y follow-up ( ClinicalTrials.gov NCT00187837 and NCT00187850).

One-step partial or complete caries removal and bonding with antibacterial or traditional self-etch adhesives: study protocol for a randomized controlled trial

BACKGROUND

Current concepts in conservative dentistry advocate minimally invasive dentistry and pulp vitality preservation. Moreover, complete removal of carious dentin in deep carious lesions often leads to pulp exposure and root canal treatment, despite the absence of irreversible pulp inflammation. For years, partial caries removal has been performed on primary teeth, but little evidence supports its effectiveness for permanent teeth. Furthermore, the recent development of new antibacterial adhesive systems could be interesting in the treatment of such lesions. The objectives of this study are to compare the effectiveness of partial versus complete carious dentin removal in deep lesions (primary objective) and the use of an antibacterial versus a traditional two-step self-etch adhesive system (main secondary objective).

METHODS/DESIGN

The DEep CAries Treatment (DECAT) study protocol is a multicenter, randomized, controlled superiority trial comparing partial versus complete caries removal followed by adhesive restoration. The minimum sample size required is 464 patients. Two successive randomizations will be performed (allocation ratio 1:1): the first for the type of excavation (partial versus complete) and the second (if no root canal treatment is required) for the type of adhesive (antibacterial versus traditional). For the two objectives, the outcome is the success of the treatment after 1 year, measured according to a composite outcome of five FDI criteria: material fracture and retention, marginal adaptation, radiographic examination (including apical pathologies), postoperative sensitivity and tooth vitality, and carious lesion recurrence.

DISCUSSION

The study will investigate the interest of a conservative approach for the management of deep carious lesions in terms of dentin excavation and bioactive adhesive systems. The results may help practitioners achieve the most efficient restorative procedure to maintain pulp vitality and increase the restoration longevity.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02286388 . Registered in November 2014.

Microbiological analysis after complete or partial removal of carious dentin using two different techniques in primary teeth: A randomized clinical trial

Background:

The management of deep carious lesions can be done by various techniques but residual caries dilemma still persists and bacterial reduction in cavities treated by either partial or complete caries removal techniques is debatable. So the objective of the present randomized clinical trial was to compare microbial counts in cavities submitted to complete caries removal and partial caries removal using either hand instruments or burs before and after 3 weeks of restoration.

Materials and Methods:

Primary molars with acute carious lesions in inner half of dentine and vital pulp were randomly divided into three groups of 14 each: Group A: Partial caries removal using hand instruments atraumatic restorative treatment (ART) only; Group B: Partial caries removal using bur; Group C: Complete caries removal using bur and caries detector dye. Dentine sample obtained after caries removal and 3 weeks after restoration, were subjected to microbial culture and counting (colony-forming units [CFU]/mg of dentine) for total viable bacterial count, Streptococcus spp., mutans streptococci, Lactobacillus spp.

Results:

Three techniques of caries removal showed significant (P < 0.05) reduction in all microorganisms studied after 3 weeks of evaluation, but there was no statistically significant difference in percentage reduction of microbial count among three groups.

Conclusion:

Results suggest the use of partial caries removal in a single session as compared to complete caries removal as a part of treatment of deep lesions in deciduous teeth in order to reduce the risk of pulp exposure. Partial caries removal using ART can be preferred for community settings as public health procedure for caries management.

Impact of the radiographic examination on diagnosis and treatment decision of caries lesions in primary teeth--the Caries Detection in Children (CARDEC-01) trial: study protocol for a randomized controlled trial

BACKGROUND

Although most clinical guidelines throughout the world indicate that clinicians take two bitewings for detecting caries lesions in primary molars of all children, evidence for this recommendation is essentially based on cross-sectional studies performed in laboratory settings or using convenience samples. The benefits and impact of performing radiographs on diagnosis and treatment decision of caries lesions in primary teeth, mainly considering relevant outcomes for patients, have not been evaluated yet. Thus, the aim of this randomized clinical trial will be to evaluate the impact of performing radiographic examination adjunct to the visual inspection for detecting and making treatment decision regarding caries lesions in primary teeth compared with visual inspection performed alone. We will consider different outcomes related to children's health and welfare.

METHODS/DESIGN

To reach this objective, 250 children ages 3 to 6 years who sought dental treatment in our dental school will be randomly allocated in two groups according to the diagnostic strategy used for caries detection: visual inspection performed alone or visual inspection associated to radiographic examination. Two trained and calibrated examiners will carry out the examinations and elaborate the treatment decision plan. Then, children will be treated and followed up for 2 years, with evaluations after 12 and 24 months after the inclusion of children in the study. Children will also return after 6 and 18 months to reinforce the preventive orientations. Primary outcome will be the number of dental surfaces in need of dental treatment at the follow-up. Secondary outcomes will be the components of the primary outcome separately, as well as, proportion of false-positive results, the oral health-related quality of life, cost-efficacy, cost-adjusted life years, and number of new lesions in the first permanent molars.

DISCUSSION

Our working hypothesis is that radiographic examination would actually exert little influence on patient-centered outcomes, and visual inspection would be enough as diagnostic strategy for caries detection in primary teeth.

TRIAL REGISTRATION

NCT02078453. Registered 4 March 2015.

Vital Pulp Therapies in Clinical Practice: Findings from a Survey with Dentist in Southern Brazil

Studies based on dentists' clinical practice possess vital relevance to understand factors leading the clinicians to choose by a specific technique over another. This study investigated which clinical conduct therapies are adopted by dentists in front of deep caries. Was evaluated how the place of work, post-graduate training and years since complete graduation influenced their decisions. A cross-sectional study was performed using a self-applied questionnaire with dentists (n=276) in Southern Brazil. Information regarding post-graduation training (specialization, master's or PhD), clinical experience (years since completing graduation) and place of work were investigated. The information regarding pulp vital therapies (materials for direct pulp capping; techniques for caries removal in deep cavities and strategies for indirect pulp capping) were collected by specific questions. Data were submitted to descriptive analysis and Exact Fischer Test. Response rate was 68% (187). The majority of dentists selected the calcium hydroxide (CH) as first material for direct (86.3%) and indirect (80.3%) pulp protection. Partial caries removal was reported by 61.9% of dentists. Less experienced clinical dentists choose partial caries removal more frequently (p=0.009), if compared with dentists graduated 10 years and up ago. The use of MTA was more common among professionals working at academic environment. Besides, MTA was not mentioned by professionals working exclusively in the public health service (p=0.003). In conclusion, the time since graduation influenced the clinical conduct related to caries removal. The choice of liner materials was influenced by dentists' workplace.

Micro-invasive interventions for managing proximal dental decay in primary and permanent teeth

BACKGROUND

Proximal dental lesions, limited to dentine, are traditionally treated by invasive (drill and fill) means. Non-invasive alternatives (e.g. fluoride varnish, flossing) might avoid substance loss but their effectiveness depends on patients' adherence. Recently, micro-invasive approaches for treating proximal caries lesions have been tried. These interventions install a barrier either on top (sealing) or within (infiltrating) the lesion. Different methods and materials are currently available for micro-invasive treatments, such as sealing via resin sealants, (polyurethane) patches/tapes, glass ionomer cements (GIC) or resin infiltration.

OBJECTIVES

To evaluate the effects of micro-invasive treatments for managing proximal caries lesions in primary and permanent dentition in children and adults.

SEARCH METHODS

We searched the following databases to 31 December 2014: the Cochrane Oral Health Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID, EMBASE via OVID, LILACs via BIREME Virtual Health Library, Web of Science Conference Proceedings, ZETOC Conference Proceedings, Proquest Dissertations and Theses, ClinicalTrials.gov, OpenGrey and the World Health Organization (WHO) International Clinical Trials Registry Platform. We searched the metaRegister of Controlled Trials to 1 October 2014. There were no language or date restrictions in the searches of the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials of at least six months' duration that compared micro-invasive treatments for managing non-cavitated proximal dental decay in primary teeth, permanent teeth or both, versus non-invasive measures, invasive means, no intervention or placebo. We also included studies that compared different types of micro-invasive treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed the risk of bias. We used standard methodological procedures expected by Cochrane to evaluate risk of bias and synthesise data. We conducted meta-analyses with the random-effects model, using the Becker-Balagtas method to calculate the odds ratio (OR) for lesion progression. We assessed the quality of the evidence using GRADE methods.

MAIN RESULTS

We included eight trials, which randomised 365 participants. The trials all used a split-mouth design, some with more than one pair of lesions treated within the same participant. Studies took place in university or dental public health clinics in Brazil, Colombia, Denmark, Germany, Thailand, Greenland and Chile. Six studies evaluated the effects of micro-invasive treatments in the permanent dentition and two studies on the primary dentition, with caries risk ranging from low to high. Investigators measured caries risk in different studies either by caries experience alone or by using the Cariogram programme, which combines eight contributing factors, including caries experience, diet, saliva and other factors related to caries. The follow-up period in the trials ranged from one to three years. All studies used lesion progression as the primary outcome, evaluating it by different methods of reading radiographs. Four studies received industry support to carry out the research, with one of them being carried out by inventors of the intervention.We judged seven studies to be at high overall risk of bias, primarily due to lack of blinding of participants and personnel. We evaluated intervention effects for all micro-invasive therapies and analysed subgroups according to the different treatment methods reported in the included studies.Our meta-analysis, which pooled the most sensitive set of data (in terms of measurement method) from studies presenting data in a format suitable for meta-analysis, showed that micro-invasive treatment significantly reduced the odds of lesion progression compared with non-invasive treatment (e.g fluoride varnish) or oral hygiene advice (e.g to floss) (OR 0.24, 95% CI 0.14 to 0.41; 602 lesions; seven studies; I(2) = 32%). There was no evidence of subgroup differences (P = 0.36).The four studies that measured adverse events reported no adverse events after micro-invasive treatment. Most studies did not report on any further outcomes.We assessed the quality of evidence for micro-invasive treatments as moderate. It remains unclear which micro-invasive treatment is more advantageous, or if certain clinical conditions or patient characteristics are better suited for micro-invasive treatments than others.

AUTHORS' CONCLUSIONS

The available evidence shows that micro-invasive treatment of proximal caries lesions arrests non-cavitated enamel and initial dentinal lesions (limited to outer third of dentine, based on radiograph) and is significantly more effective than non-invasive professional treatment (e.g. fluoride varnish) or advice (e.g. to floss). We can be moderately confident that further research is unlikely to substantially change the estimate of effect. Due to the small number of studies, it does remain unclear which micro-invasive technique offers the greatest benefit, or whether the effects of micro-invasive treatment confer greater or lesser benefit according to different clinical or patient considerations.

Teaching and practical guidelines in pulp therapy in primary teeth in Colombia - South America

OBJECTIVE

To describe the teaching practical guidelines in pulp therapy for primary teeth in Colombian dental schools, based on Primosch et al. survey (1997).

METHODS

A 27-question survey was sent to 31 dental schools. A total of 68 surveys were obtained for analysis of the results, in which pediatric dentists answered 48 surveys, 11 surveys by general practitioners, and 9 were answered but were not identified in any of these groups.

RESULTS

Indirect pulp treatment (IPT) is taught by pediatric dentists (83%) and general practitioners (90%). Calcium hydroxide and glass ionomer were the preferred materials in this treatment. Pulpotomy is the most commonly procedure used. There was no different percentage in the use of medicaments: cresatin, glutaraldehyde, calcium hydroxide, formocresol. Pulpectomy is taught by general practitioners (73%) and pediatric dentists (96%). The preferred filler material, used by general practitioners (73%) and pediatric dentists (94%), was zinc oxide and eugenol.

CONCLUSIONS

There is a discrepancy in the choice of treatment and medications for pulp therapy primary teeth between general practitioners and pediatric dentists. The recommendations given in American Academy of Pediatric Dentistry (AAPD) guidelines 2012 for pulp therapy in primary and young permanent teeth are being followed in the majority instances.

Antimicrobial activity of alexidine, chlorhexidine and cetrimide against Streptococcus mutans biofilm

Background

The use of antimicrobial solutions has been recommended to disinfect demineralized dentin prior to placing the filling material. The aim of this study was to evaluate the ability of several antimicrobials in controlling Streptococcus mutans (SM) biofilm formed in dentin.

Methods

Antimicrobial activity of 0.2% and 2% chlorhexidine (CHX), 0.2% cetrimide (CTR) and 0.2%, 0.5%, 1% and 2% alexidine (ALX) was assayed on 1-week SM biofilm formed on standardized coronal dentin blocks. Results of SM biofilm antimicrobial activity by different protocols were expressed as the kill percentage of biofilm and the term “eradication” was used to denote the kill of 100% of the bacterial population. To compare the efficacies of the different protocols the Student t test was used, previously subjecting data to the Anscombe transformation.

Results

All ALX concentrations tested and 0.2% CTR achieved a kill percentage higher than 99%, followed by 2% CHX with percentages above 96% (no statistically significant difference among them). Whereas 2% ALX and 0.2% CTR respectively showed eradication in 10 and 9 of the twelve specimens, 0.2% CHX did not produce eradication in any case.

Conclusions

The present study shows that, when used for one minute, 2% and 1% alexidine, and 0.2% cetrimide, achieve eradication of Streptococcus mutans biofilm in most specimens when applied to a dentin-volumetric model.

Sealing versus partial caries removal in primary molars: a randomized clinical trial

BACKGROUND

The resin-based pit and fissure sealant is considered a successful tool in caries prevention, however there is a growing evidence of its use in controlling already established caries in posterior teeth. The aim of this clinical trial is to verify the efficacy of pit and fissure sealants in arresting dentinal caries lesions compared to partial excavation and restorative treatment in primary molar teeth.

METHODS

Thirty six patients with occlusal cavitated primary molar reaching outer half of dentin were selected. The patients were randomly allocated into two groups: sealant application (experimental group - n = 17) and restoration with composite resin (control group - n = 19). Clinical and radiograph evaluation were performed after 6, 12 and 18 months. The chi-square test was used to verify the distribution of characteristics variables of the sample among the groups. The survival rate of treatments was evaluated using Kaplan-Meier survival and log-rank test. Fisher's Exact and logistic regression tests were calculated in each evaluation period (α = 5%).

RESULTS

The control group showed significantly better clinical survival after 18 months (p = 0.0025). In both groups, no caries progression was registered on the radiographic evaluations.

CONCLUSIONS

Sealing had similar efficacy in the arrestment of caries progression of cavitated occlusal lesions compared to partial excavation of the lesions, even though the frequency of re-treatments was significantly higher in sealed lesions.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos (ReBEC): RBR-9kkv53.

Comparison of intervention effects in split-mouth and parallel-arm randomized controlled trials: a meta-epidemiological study

Background

Split-mouth randomized controlled trials (RCTs) are popular in oral health research. Meta-analyses frequently include trials of both split-mouth and parallel-arm designs to derive combined intervention effects. However, carry-over effects may induce bias in split- mouth RCTs. We aimed to assess whether intervention effect estimates differ between split- mouth and parallel-arm RCTs investigating the same questions.

Methods

We performed a meta-epidemiological study. We systematically reviewed meta- analyses including both split-mouth and parallel-arm RCTs with binary or continuous outcomes published up to February 2013. Two independent authors selected studies and extracted data. We used a two-step approach to quantify the differences between split-mouth and parallel-arm RCTs: for each meta-analysis. First, we derived ratios of odds ratios (ROR) for dichotomous data and differences in standardized mean differences (∆SMD) for continuous data; second, we pooled RORs or ∆SMDs across meta-analyses by random-effects meta-analysis models.

Results

We selected 18 systematic reviews, for 15 meta-analyses with binary outcomes (28 split-mouth and 28 parallel-arm RCTs) and 19 meta-analyses with continuous outcomes (28 split-mouth and 28 parallel-arm RCTs). Effect estimates did not differ between split-mouth and parallel-arm RCTs (mean ROR, 0.96, 95% confidence interval 0.52–1.80; mean ∆SMD, 0.08, -0.14–0.30).

Conclusions

Our study did not provide sufficient evidence for a difference in intervention effect estimates derived from split-mouth and parallel-arm RCTs. Authors should consider including split-mouth RCTs in their meta-analyses with suitable and appropriate analysis.

Concordance between clinical practice and published evidence: findings from The National Dental Practice-Based Research Network

BACKGROUND

Documenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network ("the network").

METHODS

Network dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent ("1") or inconsistent ("0") with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence.

RESULTS

The authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent).

CONCLUSION

Dentists reported a medium-range concordance between practice and published evidence.

PRACTICAL IMPLICATIONS

Efforts to bring research findings into routine practice are needed.

A novel glass ionomer cement containing MgCO(3 )apatite induced the increased proliferation and differentiation of human pulp cells in vitro

This study aimed to investigate the in vitro biological response of human dental pulp cells to glass ionomer cement (GIC, Fuji IX GP(®)) containing 2.5% magnesium carbonate apatite (MgCO(3)Ap). MgCO(3)Ap was synthesized by wet method and characterized using FT-IR, XPS, and SEM. Fuji IX GP(®) served as a control. Test and control cements were prepared by encapsulated mixing the powder with Fuji IX-liquid (P/L=3.6:1). Eluates from cements extracted by 1 mL culture medium were collected at day 1, 7 and 14, and used for WST-1 proliferation assay. For ALPase activity, cells were maintained with cements in transwells, harvested and enzyme activity was measured at day 1, 4, 7, 14, and 21. We found a higher cell proliferation and increased ALPase activity by pulp cells in the test group compared to the control. This suggests the potential of GIC containing this novel biological apatite as a restorative material for pulp-dentin regeneration.

Partial caries removal may have advantages but limited evidence on restoration survival

DATA SOURCES

Cochrane Oral Health Group's Trials Register, CENTRAL, Medline via OVID, EMBASE via OVID; no restrictions on language or date of publication.

STUDY SELECTION

Parallel group and split mouth randomised and quasi-randomised controlled trials comparing stepwise, partial and no dentinal caries removal with complete caries removal in unrestored primary and permanent teeth were included in this review.

DATA EXTRACTION AND SYNTHESIS

Title and abstract screening was by two reviewers, with disagreements resolved by a third. Full texts of eligible studies were assessed by the team until consensus, and data extraction was by three reviewers independently and in triplicate. Two reviewers assessed risk of bias. Trial authors were contacted where possible .

RESULTS

Eight trials (all assessed as high risk of bias) with 934 participants and 1372 teeth were included in this updated review (Previously complete or ultraconservative removal of decayed tissue in unfilled teeth, Ricketts, 2006) with four new trials being included. There were a number of different comparisons in the trials (stepwise or partial or no dentinal caries removal compared to complete caries removal) with one study including more than one of these comparisons. Four studies investigated primary teeth, three permanent teeth and one included both.For stepwise caries removal, (four studies), there was a 56% reduction in incidence of pulp exposure (RR 0.44, 95% CI 0.33 to 0.60, P < 0.00001) compared to complete caries removal. The mean pulp exposure incidence was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was no difference in signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50).In the two partial caries removal studies, the incidence of pulp exposure reduction was 77% for the partial caries removal group (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009) with a mean pulp exposure incidence of 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15), or restoration failure (one study showing no difference and another study showing no failures in either group).There were two very different studies which looked at no dentinal caries removal compared to complete caries removal. There was some evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure, favouring no dentinal caries removal, from one study. There were no instances of pulp disease or restoration failure in either group from the second study. Meta-analysis of these two studies was not carried out because of the substantial clinical differences between the studies.

CONCLUSIONS

For management of dentinal caries, both stepwise and partial excavation showed clinical advantage over complete caries removal by reducing the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. The review found no difference in signs or symptoms of pulpal disease between stepwise excavation and complete caries removal.There was insufficient evidence to determine whether there was a difference in signs and symptoms of pulp disease or a difference in the risk of restoration failure with partial caries removal.For the two no dentinal caries removal studies, the one investigating permanent teeth found no difference in restoration failure and the one investigating primary teeth found a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up, low reporting of patient centred outcomes and high risk of bias, further high quality, long-term clinical trials are still required to assess the most effective intervention.

Operative caries management in adults and children

BACKGROUND

The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 12 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 12 December 2012) and EMBASE via OVID (1980 to 12 December 2012). There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Parallel group and split-mouth randomised and quasi-randomised controlled trials comparing stepwise, partial or no dentinal caries removal with complete caries removal, in unrestored primary and permanent teeth were included.

DATA COLLECTION AND ANALYSIS

Three review authors extracted data independently and in triplicate and assessed risk of bias. Trial authors were contacted where possible for information. We used standard methodological procedures exacted by The Cochrane Collaboration.

MAIN RESULTS

In this updated review, four new trials were included bringing the total to eight trials with 934 participants and 1372 teeth. There were three comparisons: stepwise caries removal compared to complete one stage caries removal (four trials); partial caries removal compared to complete caries removal (three trials) and no dentinal caries removal compared to complete caries removal (two trials). (One three-arm trial compared complete caries removal to both stepwise and partial caries removal.) Four studies investigated primary teeth, three permanent teeth and one included both. All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I(2) = 0%) compared to complete caries removal based on moderate quality evidence, with no heterogeneity. In these four studies, the mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups. There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I(2) = 0%).Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I(2) = 0%), also based on moderate quality evidence with no evidence of heterogeneity. In these two studies the mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups. There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I(2) = 0%, low quality evidence), or restoration failure (one study showing no difference and another study showing no failures in either group, very low quality evidence).No dentinal caries removal was compared to complete caries removal in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies.

AUTHORS' CONCLUSIONS

Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.Due to the short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

Incomplete Caries Removal

Increasing numbers of clinical trials have demonstrated the benefits of incomplete caries removal, in particular in the treatment of deep caries. This study systematically reviewed randomized controlled trials investigating one- or two-step incomplete compared with complete caries removal. Studies treating primary and permanent teeth with primary caries lesions requiring a restoration were analyzed. The following primary and secondary outcomes were investigated: risk of pulpal exposure, post-operative pulpal symptoms, overall failure, and caries progression. Electronic databases were screened for studies from 1967 to 2012. Cross-referencing was used to identify further articles. Odds ratios (OR) as effect estimates were calculated in a random-effects model. From 364 screened articles, 10 studies representing 1,257 patients were included. Meta-analysis showed risk reduction for both pulpal exposure (OR [95% CI] 0.31 [0.19-0.49]) and pulpal symptoms (OR 0.58 [0.31-1.10]) for teeth treated with one- or two-step incomplete excavation. Risk of failure seemed to be similar for both complete and incomplete excavation, but data for this outcome were of limited quality and inconclusive (OR 0.97 [0.64-1.46]). Based on reviewed studies, incomplete caries removal seems advantageous compared with complete excavation, especially in proximity to the pulp. However, evidence levels are currently insufficient for definitive conclusions because of high risk of bias within studies.

Indirect pulp therapy in a symptomatic mature molar using calcium enriched mixture cement

Dental pulp has the ability of repair/regeneration. Indirect pulp therapy (IPT) is recommended for pulp preservation in asymptomatic teeth with extremely deep caries as well as teeth with clinical symptoms of reversible pulpitis. In this case study, we performed IPT with calcium enriched mixture (CEM) cement on a symptomatic permanent molar. After clinical/radiographic examinations the tooth was diagnosed with irreversible pulpitis and associated apical periodontitis. IPT involved partial caries removal, the placement of CEM cement pulp cap and overlying adhesive permanent restoration. At the 1 week follow-up, patient's spontaneous symptoms had resolved. One-year follow-up demonstrated pulp vitality, clinical function, as well as the absence of pain/tenderness to percussion/palpation/cold sensitivity tests; periapical radiograph showed a healing periradicular lesion with newly formed bone, that is normal pulp with normal periodontium. These favorable results indicate that IPT/CEM may be a good treatment option in comparison to endodontic treatment in young patients. IPT of deep-caries lesion is an easier, more practical and valuable treatment plan than complete caries removal.

The Hall technique may be an effective treatment modality for caries in primary molars

Subjects

From 2001 to 2004, 17 general dental practitioners (GDPs) in Tayside, Scotland, recruited 132 children aged 3 to 10 years at enrollment who had caries affecting matched pairs of asymptomatic primary molar teeth for participation in this split-mouth randomized controlled trial. Of these 264 study teeth with caries lesions, 42% were radiographically more than halfway into dentin, and 67% required Class II restorations. In 2000, the regional decayed/missing/filled teeth (DMFT) number was 2.47 (d3 1.71; mt 0.54; ft 0.22). Ninety-one patients (69%) had 48 months minimum of follow-up, or both teeth had reached an end point (ie, extracted, exfoliated, censored) before this time.

Key Exposure/Study Factor

One molar tooth in the study pair was allocated to the Hall technique (HT) (intervention), and the contralateral tooth was allocated to the practitioner’s usual treatment (control). Practitioners accessed computer-generated randomization for treatment allocation and order by telephoning a central administrator. According to the HT protocol, food could be removed from the cavity, but there was to be no other cavity preparation. The correct size of crown was selected, and the crown and tooth were washed and dried. The crown was filled with glass-ionomer cement (GIC) and seated with digital pressure before the child was instructed to bite down hard to seat the crown fully. Excess GIC was removed, and the child was instructed to continue biting down until the cement had set.

Main Outcome Measure

Major failures were indicated by the signs and symptoms of irreversible pulpitis or dental abscess (requiring pulp therapy or extraction), interradicular radiolucency, restoration loss and unrestorable tooth, and internal root resorption.

Main Results

At 60 months, for 91 patients with at least 48 months of follow-up, major failures (ie, irreversible pulpitis, loss of vitality, abscess, or unrestorable tooth) were recorded for 18 teeth: 3 (3%) for HT (treatment arm) and 15 (16.5%) for the usual treatment (control) (P = .000488; number-needed-to-treat [NNT] = 8).

Conclusion

The authors concluded that sealing in caries by using the HT was more effective statistically and clinically, in the long term, and significantly outperformed the GDPs’ standard restorations.

Effect of silver diamine fluoride on microtensile bond strength to dentin

The aim of this in vitro study was to investigate the effect of the cariostatic and preventive agent silver diamine fluoride (SDF) on the microtensile bond strength of resin composite to dentin. Forty-two caries-free, extracted molars were flattened occlusally and apically using a diamond saw, and the exposed occlusal dentin was polished with a series of silicon carbide papers, all under water irrigation. The teeth were then randomly divided into six groups of seven teeth each that were treated as follows: 1) Peak SE self-etch bonding agent; 2) 12% SDF + Peak SE; 3) 38% SDF + Peak SE; 4) Peak LC etch-and-rinse bonding agent; 5) 12% SDF + Peak LC; and 6) 38% SDF + Peak LC. Four-millimeter buildups of Amelogen Plus were incrementally placed on all teeth; after a 24-hour storage period in distilled water, the specimens were sectioned perpendicular to the adhesive interface to produce beams of cross-sectional surface area measuring approximately 1 mm(2). The beams were placed on a microtensile testing machine, which utilized a single-speed pump motor and force gauge at 20 kgf × 0.01 second to record maximum tensile force before failure occurred. Two-way analysis of variance and post hoc Tukey tests were performed to compare the effects of the SDF on microtensile bond strength, with statistical significance set at α = 0.05. None of the experimental groups treated with different concentrations of SDF showed a significant difference in bond strength compared to the control groups, and there was no significant difference in bond strength between self-etch and etch-and-rinse groups. However, the effect of SDF on self-etch bonded teeth compared to etch-and-rinse bonded teeth was statistically significant (p=0.0363), specifically at the 12% concentration. SDF does not adversely affect the bond strength of resin composite to noncarious dentin.

Sealing caries in primary molars: randomized control trial, 5-year results

The Hall Technique (HT) is a method for managing carious primary molars. Decay is sealed under pre-formed metal crowns without any caries removal, tooth preparation, or local anesthesia. The aim of this study was to compare HT clinical/radiographic failure rates with General Dental Practitioners' (GDPs) standard (control) restorations. We conducted a split-mouth, randomized control trial (132 children, aged 3-10 yrs, GDPs n = 17) in Scotland. There were 264 study teeth with initial lesions, 42% of which were radiographically > half-way into dentin, and 67% of which had Class II restorations. Teeth were randomized to HT (intervention) or GDPs' usual treatment (control). Annual clinical/radiographic follow-up data were recorded. Ninety-one patients (69%) had 48 months' minimum follow-up. At 60 months, 'Major' failures (irreversible pulpitis, loss of vitality, abscess, or unrestorable tooth) were recorded: HT, 3 (3%); control restorations, 15 (16.5%) (p = 0.000488; NNT 8); and 'Minor' failures (reversible pulpitis, restoration loss/wear/fracture; or secondary caries): HT, 4 (5%); control restorations, 38 (42%) (p < 0.000001; NNT 3). Overall, there were follow-up data for 130 patients (2-60 mos): 'Major' failures: HT, 3 (2%); control restorations, 22 (17%) (p = 0.000004; NNT 7); and 'Minor' failures, HT, 7 (5%); control restorations, 60 (46%) (p < 0.000001; NNT 3). Sealing in caries by the Hall Technique statistically, and clinically, significantly outperformed GDPs' standard restorations in the long term (Trial registration no. ISRCTN 47267892).