Interventions for treating cavitated or dentine carious lesions

Vital pulp therapies in permanent teeth: what, when, where, who, why and how?

The dentine-pulp complex is a unique organ that provides nourishment to the dentine and supports the tooth's innervation and defence system. Preserving its health is a key aspect of minimally invasive dentistry. Vital pulp therapies (VPTs), as defined by the European Society of Endodontology, are 'treatment strategies aimed at maintaining the health of all or part of the pulp'. These therapies are particularly useful when pulp inflammation, caused by caries or trauma, threatens pulp vitality and may otherwise lead to necrosis and the need for invasive treatment. VPTs offer several advantages, including the retention of the pulp's immunological functions, maintenance of the structural integrity of the tooth, reduced patient pain and simplified treatment protocols. Additionally, these therapies lower the costs and inconvenience associated with more invasive treatments, benefiting both patients and society. A range of protocols and key factors promoting successful outcomes have been described to guide dental practitioners in adopting VPTs where appropriate. Future considerations for pragmatic research and implementation in primary care are essential to create a sustainable use of VPTs, thus promoting better oral health.

Success rate of Hall Technique for restoring carious primary molars - systematic review and meta-analysis

OBJECTIVES

The overall pooled success rate of the Hall Technique (HT) in various types of studies has not been investigated. The present study aims to evaluate the success rate of HT to restore carious primary molars.

METHODS

A systematic search was carried out in the MEDLINE/PubMed, Excerpta Medica Database (EMBASE), Scopus, Web of Science, and LIVIVO electronic databases, as well as the ProQuest database for grey literature review. A search was carried out up to September 2023 for studies meeting the eligibility criteria: Randomised Clinical Trials (RCTs) and Non-Randomised Studies of Interventions (NRSIs); children with primary molars treated using HT; and reporting success for at least 1-month post-treatment. Single-arm meta-analysis assessed the pooled proportion (95% CI) of HT success rates. Risk of bias and certainty of evidence using the GRADE approach were assessed.

RESULTS

Searching identified 665 studies, with 25 (15 RCTs and 10 NRSIs) meeting the eligibility criteria. In meta-analyses of RCTs, the pooled proportion success rate was 98% (95% CI: 97-99%) at 12-month follow-up. For NRSIs, the pooled proportion success rate was 95% (95% CI: 91-100%) up to 89 months.

CONCLUSIONS

HT presents a high success rate, even though the primary studies had "low" to "high" risk of bias and demonstrated "moderate" to "low" certainty of evidence. One of the main reasons for downgrading was related to blinding, which was generally unfeasible due to visibly different restorative materials. The systematic review protocol was registered in PROSPERO (ID: CRD42021204415).

Assessment of two methods for detecting carious dentin: an in vitro study

BACKGROUND

The objective of this study was to compare, in vitro, two dentinal caries lesion detector methods, Caries Finder and BlueCheck, to determine if they were substantially equivalent in their ability to aid visualization of demineralized dentin and to also to compare their performance compared to the traditional visual/tactile method of dentinal caries lesion detection in vitro.

METHODS

Sixty-five extracted human teeth containing lesions rated as ICDAS 4,5 or 6 were chosen and then randomly assigned to two groups. Specimens were then evaluated in standard operatory conditions by three evaluators using the traditional visual and tactile method, the Caries Finder method, and the BlueCheck method of detection. The study employed a parallel, randomized controlled study design. To test the equivalence claim, a "two-one sided test" (TOST) approach was utilized.

RESULTS

As compared to the traditional method, the Caries Finder method had a 0.9742 accuracy, 95% confidence interval [0.9578, 0.9855], 94.80% sensitivity, 98.53% specificity, 96.47% positive predictive value, 97.82% negative predictive value, 0.938 Kappa value, p < 2.2e-16). The BlueCheck method had a 0.9821 accuracy, 95% confidence interval [0.9682, 0.9910], 96.02% sensitivity, 99.09% specificity, 97.69% positive predictive value, 98.42% negative predictive value, 0.956 Kappa value, p < 2.2e-16). Inter-rater reliability and intra-rater reliability ratings were good to excellent.

CONCLUSIONS

The results of this study support the conclusion that the Caries Finder and BlueCheck methods compare favorably with the traditional method of carious dentin detection. Caries Finder and BlueCheck detection methods were found to have comparable performance in their ability to differentiate carious dentin from healthy tooth structure in vitro; however further in vivo validation is required to confirm clinical equivalence. Both show good to excellent inter-rater and intra-rater reliability.

Deep caries and pulp exposures management preferences in permanent teeth: A survey amongst Spanish dentists

AIM

To assess Spanish dentists' management preferences for deep caries removal and exposed pulps in permanent teeth.

METHODOLOGY

A web-based open and anonymous survey was distributed by social media and a specific website for this project amongst dentists practicing in Spain. The questionnaire comprised 40 questions, divided into five sections: (1) demographic data and professional activity; (2) carious tissue removal; (3) decision-making regarding pulp exposure; (4) direct pulp capping and (5) pulpotomy procedures in permanent teeth. Results were descriptively analysed. Logistic regression (95% CI) analyses and X2 tests were carried out.

RESULTS

A total of 538 responses were received. Half the respondents (53.7%) preferred to perform complete caries excavation for shallow and moderate carious dentin lesions, and selective excavation to firm dentin for deep lesions (57.8%). Selective removal to soft dentin and stepwise removal were much less indicated (15.4% and 10.9%, respectively). Exposed pulps in asymptomatic teeth were treated by direct pulp capping (over 80%), decreasing in the presence of reversible pulpitis symptoms (57.1%). If irreversible pulpitis was diagnosed, a pulpectomy would be performed by 53.5% and 89.9% of the respondents in, respectively, immature and mature teeth. Pulpotomy was performed routinely only by 26.4% of the clinicians. Patients' attitudes and priorities were the most relevant criteria when performing direct pulp capping and pulpotomy, together with the history of pain and the presence of bleeding. Regarding the clinical procedure, dry cotton was preferred to obtain haemostasis and Biodentine was the material of election.

CONCLUSIONS

Caries removal preferences and management of pulp exposure by dentists practicing in Spain deviated from vital pulp treatment guidelines, mainly regarding indications and case selection. Pulp exposure was managed by direct pulp capping in asymptomatic cases, whilst immature permanent molars favoured the indication of pulpotomy when pulpitis was diagnosed. Most clinicians used hydraulic calcium silicate cement, specifically Biodentine, to perform vital pulp treatments. Postgraduate formation and continuing education in caries lesions management and vital pulp treatments were consistently related to more conservative and updated decisions.

Vital Pulp Therapy: Evidence-Based Techniques and Outcomes

Vital pulp therapy (VPT) comprises a range of conservative treatment modalities aimed at preserving the vitality of the compromised dental pulp in primary and permanent teeth. This PubMed-based review comprehensively evaluates seven distinct VPT techniques; including their historical development, broad definitions, clinical protocols and treatment outcomes as evidenced by systematic reviews and meta-analyses. The VPT modalities covered in this review include stepwise excavation, indirect pulp capping, direct pulp capping, miniature pulpotomy, partial pulpotomy, full pulpotomy and partial pulpectomy. Stepwise excavation, as a minimally-invasive option, has demonstrated effectiveness in reducing the risk of pulp exposure, particularly in permanent teeth. Clinical outcomes of indirect and direct pulp capping are promising; specifically with the application of advanced calcium silicate cements. Miniature and partial pulpotomies emphasize the importance of precise definitions and standardised protocols due to their subtle differences. Full pulpotomy has emerged as a viable alternative to root canal treatment, achieving comparable success rates in managing irreversible pulpitis. While partial pulpectomy remains the most invasive approach, it has shown potential in managing complex cases, such as root resorption, through selective tissue preservation. Despite advancements in biomaterials and technique standardisation, challenges remain, including variability in clinical protocols, limited high-quality evidence, and the need for long-term studies to better evaluate anticipated outcomes. Nevertheless, emerging biotechnologies hold promise for enhancing the precision and predictability of VPT procedures in the future.

Direct Composite Restorations on Permanent Teeth in the Anterior and Posterior Region - An Evidence-Based Clinical Practice Guideline - Part 2: Recommendations for Composite Processing

PURPOSE

Part 2 of this German S3 clinical practice guideline provides recommendations for the process of manufacturing composite restorations. It covers key aspects like caries removal, field isolation, matrix and adhesive techniques, as well as light curing and polishing. The outcomes of interest include survival rates and restoration quality.

MATERIALS AND METHODS

A systematic literature search was conducted by two methodologists using MEDLINE and the Cochrane Library via the OVID platform, including studies up to December 2021. Additionally, the reference lists of relevant manuscripts were manually reviewed. Six PICO questions were developed to guide the search. Consensus-based recommendations were for- mulated by a panel of dental professionals from 20 national societies and organizations based on the collected evidence and ex- pert opinion.

RESULTS

The guideline advocates for one-stage selective caries removal near the pulp and underscores the effectiveness of various isolation techniques, adhesive systems, and the crucial role of light polymerization. The use of anatomically pre- formed sectional matrices and phosphoric acid etching is recommended to enhance restoration quality. Additionally, polish- ing composite restorations is advised to improve surface finish.

CONCLUSION

This guideline provides comprehensive recommendations that inform clinicians on optimizing the composite restor- ation manufacturing processes. The adoption of these best practices can improve the quality and longevity of dental restorations.

Effect of silver diamine fluoride and potassium iodide on shear bond strength for glass ionomer cement to primary dentine

Silver diamine fluoride (SDF) is a highly effective topical fluoride for halting dental caries; however, it darkens both teeth and restorations. Therefore, it is of interest to assess the shear bond strength (SBS) of glass ionomer cement (GIC) to caries-affected dentin treated with SDF alone and SDF followed by KI. Forty primary molar samples were prepared to reveal a flat dentin surface and were randomly assigned to two groups. In group A, the dentin surfaces were pre-treated with 38% SDF, while in group B, the dentin was treated first with SDF and then with KI before being restored with GIC. The SBS was measured using a universal testing machine. The results show that teeth pre-treated with both SDF and KI demonstrated significantly improved bond strength of GIC to dentin compared to SDF treatment alone.

AI-initiated second opinions: a framework for advanced caries treatment planning

Integrating artificial intelligence (AI) into medical and dental applications can be challenging due to clinicians' distrust of computer predictions and the potential risks associated with erroneous outputs. We introduce the idea of using AI to trigger second opinions in cases where there is a disagreement between the clinician and the algorithm. By keeping the AI prediction hidden throughout the diagnostic process, we minimize the risks associated with distrust and erroneous predictions, relying solely on human predictions. The experiment involved 3 experienced dentists, 25 dental students, and 290 patients treated for advanced caries across 6 centers. We developed an AI model to predict pulp status following advanced caries treatment. Clinicians were asked to perform the same prediction without the assistance of the AI model. The second opinion framework was tested in a 1000-trial simulation. The average F1-score of the clinicians increased significantly from 0.586 to 0.645.

Biodentine™ as a temporary filling in deep carious lesions in permanent teeth: a prospective observational 33-month follow-up study

PURPOSE

The study aimed to evaluate temporary fillings using Biodentine™ in asymptomatic deep carious lesions after 12, 24, and 36 months in school children from the remote village of Kerung, Nepal.

METHODS

From November 2018 to November 2019, 91 temporary fillings were placed using Biodentine™ (a hydraulic calcium silicate cement) in permanent molars with deep carious lesions of schoolchildren in the remote district of Kerung, Nepal. These restorations were performed after selective caries removal in a non-dental setting with hand instruments and cotton roll isolation, as electric motors and saliva ejection systems were unavailable. In total, 78 single-surface and 13 multi-surface fillings were placed. Clinical and radiographic follow-up periods encompassed 12, 21, and 33 months, respectively.

RESULTS

After 12 months, all single-surface fillings (100%) survived, whilst all multi-surface fillings were partially or entirely lost. The survival rate of single-surface restorations after 21 and 33 months was 67.6% and 50%, respectively. Radiographically, no pathology was observed.

CONCLUSION

This study showed that Biodentine could be used in deep carious lesions as a temporary filling in single-surface lesions for at least up to 1 year and in a substantial number of cases for up to 21 and 33 months.

Comparing the effectiveness of caries arrest by micro-operative treatment to operative treatment: A 2-year randomized controlled clinical trial

OBJECTIVES

To compare the effectiveness of caries arrest by micro-operative treatment (sealing) to operative treatment (flowable resin composite restoration) through a 2-year randomized controlled clinical trial.

MATERIALS AND METHODS

A prospective randomized controlled trial was conducted among 7-9-year-old children. At baseline, 630 subjects were screened and 92 children who had at least one carious lesion classified as ICDAS 3 on the pit and fissure of first permanent molar were included. Then they were randomly assigned to the sealant group (73 lesions) and the flowable resin composite group (76 lesions) to receive the corresponding intervention. Lesions status in each group was evaluated every 6 months up to 24 months. Clinical progression of dental caries and materials retention were the outcomes used for group comparisons at p-value < 0.05.

RESULTS

After 24 months, three lesions (4.1%) in the sealant group clinically progressed to dentin caries. No lesion in the flowable composite group was observed a progression. The results of Life-table survival analysis show that the cumulative caries arrest rate had no statistically significant difference between the two groups (p = 0.075). However, the cumulative retention rate was 57.5% in the sealant group and 92.1% in the flowable composite group, with significant differences (p < 0.001). The multilevel mixed model showed the sealant had higher risk of retention failure than the flowable composite (OR = 8.66, p < 0.001), while tooth position did not influence material retention (p = 0.083). In addition, the results of Fisher Exact test show that dentin lesions had more retention failure than enamel lesions in the sealant group (p = 0.026).

CONCLUSION

Although sealing microcavitated carious lesions of the first permanent molar achieved lower retention rate than resin composite restoration, both sealing and restoration effectively arrested caries progression for two years.

CLINICAL RELEVANCE

To preserving dental structure and delaying or eliminating the need for operative procedures, microcavitated carious lesion can be arrested by sealing.

TRIAL REGISTRATION

Registered at http://www.chictr.org.cn ; Feb 15th, 2020; No. ChiCTR2000029862.

3-year randomized clinical trial to evaluate the performance of posterior composite restorations lined with ion-releasing materials

To evaluate the impact of using ion-releasing liners on the 3-year clinical performance of posterior resin composite restorations after selective caries excavation with polymer burs. 20 patients were enrolled in this trial. Each patient had two deep carious lesions, one on each side of the mouth. After selective caries removal using polymer bur (PolyBur P1, Komet, Brasseler GmbH Co. KG, Lemgo, Germany), cavities were lined with bioactive ionic resin composite (Activa Bioactive Base/Liner, Pulpdent, Watertown, MA, USA) or resin-modified glass ionomer liner (Riva Light Cure, SDI, Bayswater, Victoria, Australia). All cavities were then restored with nanofilled resin composite (Filtek Z350XT, 3M Oral Care, St. Paul, MN, USA). All the tested materials were placed according to the manufacturers' instructions. Clinical evaluation was accomplished using World Dental Federation (FDI) criteria at baseline and after 6 months, 1, 2, and 3 years. Data were analyzed using Mann-whitney U and Friedman tests (p < 0.05). The success rates were 100% for all resin composite restorations either lined with ion-releasing resin composite or resin-modified glass ionomer liner. Mann-whitney U test revealed that there were no statistically significant differences between both ion-releasing lining material groups for all criteria during the follow-up periods (p > 0.05). Resin composite restorations showed acceptable clinical performance over 3 years either lined with bioactive ionic or resin-modified glass ionomer liners after selective caries excavation preserving pulp vitality. After the 3-year follow-up period, Activa Bioactive and Riva Light Cure liners were clinically effective and they exhibited with the overlying composite restorations successful clinical performance.Trial registration number: NCT05470959. Date of registration: 22/7/2022. Retrospectively registered.

Comparative Meta-Analysis of Minimally Invasive and Conventional Approaches for Caries Removal in Permanent Dentition

Background and Objectives: Addressing deep carious lesions poses significant challenges in daily dental practice due to the inherent complexity of their treatment. Traditionally, complete removal of carious tissues has been the norm, potentially leading to pulp tissue exposure and subsequent pulpitis. In contemporary dentistry, there is a growing preference for minimally invasive techniques, such as selective removal, offering a more conservative approach with enhanced predictability and success rates. Materials and Methods: Our study commenced with a comprehensive systematic review. After that, we performed a meta-analysis focused exclusively on randomized controlled trials involving permanent dentition. Our investigation incorporated seven selected articles, which scrutinized success rates and the incidence of pulp exposure in minimally invasive techniques (MIT) versus conventional techniques (CT). Statistical analysis employed U Mann-Whitney and Wilcoxon tests to interpret the results. Results: Although the difference did not reach statistical significance, MIT demonstrated marginally superior success rates compared to CT. Furthermore, MIT exhibited a lower percentage of pulp exposure when contrasted with CT. However, due to the limited sample size, statistical significance for this difference could not be established. Conclusions: Minimally invasive techniques for caries removal emerge as a conservative and promising approach to safeguard pulp tissues in comparison to conventional techniques. The need for additional randomized controlled trials is emphasized to unequivocally establish the superior success rates of these procedures over their conventional counterparts.

Assessing the Acceptability of Less Invasive Caries Removal Techniques for treating Deep Carious Lesions: A Conjoint Survey among Dentists Practicing in a Midwestern American State

This study identified factors that influence dentists' decisions regarding less invasive caries removal techniques such as stepwise removal (SW) and selective removal (SE) using a marketing research technique, conjoint analysis. A survey was sent to 1,434 dentists practicing in Iowa. Dentists were randomly assigned to receive a questionnaire to rate the likelihood they would use either SW/SE in hypothetical clinical scenarios. The scenarios were carefully created by conjoint design and included three relevant attributes: depth of lesion, hardness of carious dentin, and patient age. Descriptive and conjoint analyses were performed to assess trade-offs between these attributes, using SPSS. The study revealed that depth of lesion was the most important factor in the dentists' decisions (49 importance value) when choosing a SW to treat a deep carious lesion, followed by hardness of carious dentin and patient age (21 importance value). For the SE group, depth of the lesion was also the predominant factor when selecting a treatment. The study also identified that a high proportion of dentists (24.9%) indicated they would never consider using SW or SE under any circumstances. Our survey showed that depth of lesion was the most important reason to select a less invasive caries removal method. The high proportion of dentists indicating they would never consider selective caries removal (SE) techniques suggests that these less invasive options are underutilized.

Knowledge and attitudes toward evidence-based cariology and restorative dentistry among Egyptian dental practitioners: a cross-sectional survey

BACKGROUND

This is the first study to assess Egyptian dental practitioners' knowledge about conservative caries management approaches and investigate whether this knowledge transfers into clinical practice and the barriers to translating research into evidence-based practice.

METHODS

A sample of dental practitioners was surveyed using an online questionnaire. Convenience and snowball sampling were used to collect data from February to June 2022. We included graduated dentists from Egyptian universities who practiced in Egypt. Data were analyzed with descriptive statistics, and the associations between variables were checked using Kruskal Wallis and Chi-Square tests.

RESULTS

This study included 396 participants from throughout Egypt. There were significant correlations between specialty and participants' knowledge and behaviors toward evidence-based caries management (p = 0.002) and between specialization and tools used to detect carious lesions (p < 0.001). Most participants (59.1%) used G.V Black's classification, and (80.8%) removed caries based on the feature of dentin hardness and color, whereas (67%) removed caries until hard dentine remained. The participants' primary hurdle to staying up-to-date was their belief that the newly gained information would not be clinically applicable due to a lack of equipment or working in low-economic areas. Patient-related barriers were the major obstacles for participants in implementing evidence-based practice.

CONCLUSION

Egyptian dentists did not fully embrace minimal invasive approaches for caries management, and practitioners' experiences continue to shape decision-making. It emphasizes the imperative to practically educate dentists using effective knowledge translation dissemination to promote evidence adoption in daily practice and advocate value-based dental care to address the economic crisis's impact on Egypt's healthcare.

Dentin Degradation: From Tissue Breakdown to Possibilities for Therapeutic Intervention

Purpose of the Review

Presently, dental materials science is driven by the search for new and improved materials that can trigger specific reactions from the affected tissue to stimulate repair or regeneration while interacting with the oral environment to promote or maintain oral health. In parallel, evidence from the past decades has challenged the exclusive role of bacteria in dentin tissue degradation in caries, questioning our understanding of caries etiopathogenesis. The goal of this review is to recapitulate the current evidence on the host and bacterial contributions to degradation, inflammation, and repair of the dentin-pulp complex in caries.

Recent Findings

Contrasting findings attribute dentin breakdown to the activity of endogenous enzymes, such as matrix metalloproteinases (MMPs) and cathepsins, while the role of bacteria and their by-products in the destruction of dentin organic matrix and pulp inflammation has been for decades supported as an incontestable paradigm. Aiming to better understand the mechanisms involved in collagen degradation by host enzymes in caries, studies have showed that these proteinases are expressed in the mature dentin (i.e., after dentin formation) and become activated by the low pH in the acidic environment resulted by bacterial metabolism in caries. However, different host sources other than dentin-bound proteinases seem to also contribute to caries progression, such as saliva and pulp. Interestingly, studies evaluating pulp responses to bacteria invasion and inflammation in caries report higher levels of MMPs and cathepsins in inflamed tissue, but also showed MMP potential to resolve inflammation and stimulate wound healing. Notably, as reported for other tissues, MMPs exert dual roles in the dentin-pulp complex in caries, participating or regulating both degradative and reparative mechanisms.

Summary

The specific roles of host and bacteria and their by-products in caries progression have yet to be clarified. The complex interactions between inflammation and repair in caries pose challenges to a clear understanding of the dentin-pulp complex responses and changes to bacteria invasion. However, it opens new venues for the development of novel therapies and dental biomaterials based on the modulation of specific mechanisms to favor tissue repair and healing.

The Remineralization Effect of Calcium Glycerophosphate in Fluoride Mouth Rinse on Demineralized Primary Enamel: An in vitro Study

Aim

To evaluate the remineralization effect of a fluoride mouth rinse containing calcium glycerophosphate in fluoride mouth rinse based on the surface microhardness of demineralized primary enamel.

Materials and Methods

40 sound primary incisors were placed into self-curing acrylic resin and subjected to a demineralizing solution for 5 days, resulting in the formation of artificial caries. The teeth were categorized into four groups (n = 10): group I artificial saliva, group II sodium fluoride, group III sodium fluoride + sodium monofluorophosphate, and group IV sodium monofluorophosphate + calcium glycerophosphate. The specimens received a pH cycling procedure and were submerged twice in their assigned groups for 7 days. The baseline, after demineralization, and after remineralization surface microhardness values were determined. One-way analysis of variance (ANOVA) was used to analyze the mean surface microhardness between groups and one-way repeated measures ANOVA for the mean surface microhardness within each group and Bonferroni's for multiple comparisons at 95% confidence level. The percentage recovery surface microhardness was determined by calculating the average surface microhardness.

Results

After demineralization, the mean surface microhardness in all groups significantly decreased. After remineralization, group I had the lowest surface microhardness values and the percentage recovery surface microhardness (P value < 0.001), and group IV had the highest surface microhardness values and the percentage recovery surface microhardness (P value < 0.001). No significant difference was found between groups II and III (P value = 0.365).

Conclusions

Fluoride mouth rinse containing calcium glycerophosphate has a remineralization effect on demineralized primary enamel.

Deep Carious Lesions Management with Stepwise, Selective, or Non-Selective Removal in Permanent Dentition: A Systematic Review of Randomized Clinical Trials

OBJECTIVE

The goal of this systematic study was to investigate the effectiveness of selective, stepwise, and non-selective removal techniques for caries removal in permanent teeth with deep carious lesions. The primary focus was the results found comparing techniques for caries removal to check whether there was pulp exposition; the secondary was the materials used for pulp protection and clinical findings reported within the included studies.

METHODS

The search was performed in two databases (PubMed/MEDLINE and Web Of Science). The studies included in this systematic review were selected based on eligibility criteria. The inclusion criteria were: (1) randomized controlled trials (RCTs), (2) that compared the total removal of carious tissue with selective removal in permanent teeth with deep carious lesions, (3) with a follow-up period of at least 6 months, and (4) publications in English. Regarding the exclusion criteria, the following were not considered: (1) articles published in other languages, (2) articles that did not compare the different types of total/selective decay removal, and (3) articles published before January 2008. The risk of bias and the quality of the included studies were independently assessed by two reviewers using the RoB 2 tool.

RESULTS

5 out of 105 potentially eligible studies were included. Regarding the teeth included in the study, three articles performed management only on permanent molars, while other studies also performed management on incisors/canines/premolars/molars. Management protocols were divided into nonselective caries removal and partial caries removal (selective/stepwise). The theory of non-selective caries removal was considered an excessive, unnecessarily invasive option and a form of outdated management, and selective removal was preferred.

CONCLUSION

The selective removal technique presented a higher success rate and fewer incidences of pulpal exposure than total removal, after up to 18 months of follow up. Moreover, only one session seemed to be a better management choice compared to two sessions because the cavity re-opening procedure is more prone to pulp exposure and highly depends on patient commitment. Otherwise, at 5 years of follow up, there was no difference between selective removal and total removal in management longevity. In addition, there were also no differences between the success of the materials used for definitive restorations in teeth subjected to any of the techniques evaluated.

Management of children with poor prognosis first permanent molars: an interdisciplinary approach is the key

Although there have been continuous improvements in child oral health over recent decades, first permanent molars (FPMs) remain susceptible to early caries and can often be affected by hypomineralisation. We highlight current thinking in caries management and the restoration of hypomineralised FPMs, while also discussing enforced loss of these teeth within the context of interceptive extractions or extractions as part of orthodontic treatment. Compromised FPMs can negatively impact on quality of life for a child and present significant management challenges for the dental team. Although a high-quality evidence base is lacking for the different treatment options, early diagnosis and multidisciplinary treatment planning are key to achieving the best outcomes.

Dental Caries and Its Management

Objectives

In recent years, the management of dental caries has evolved significantly. Caries prevention, early detection, and a diagnosis based on risk indicators and risk factor assessments are the most current practical approaches. Furthermore, as proposed in minimally invasive dentistry, the new management approaches preserve healthy tissue and maintain pulp vitality. This article overviews the latest minimally invasive dental caries management and treatment options. The information will assist the reader in the early detection, diagnosis, and treatment of dental caries.

Materials and Methods

The PubMed (MEDLINE) search engine was used to gather the most relevant information on dental caries. The search was restricted to five years (May 30, 2018-May 29, 2022), and only English-language studies were accessed. A Boolean search of the PubMed data set was implemented to combine a range of keywords. The following filters were applied: abstract, free full text, full text, clinical trial, randomised control trial, systematic review, meta-analysis, and review. More studies were also obtained by manual searches from Google Scholar and textbooks on dental caries.

Results

By using this process, 683 articles and studies were obtained. The most relevant published studies were chosen and used in the current review. The selected articles are included in the references list. However, the search extended to cover the last five years as our understanding and management of dental caries have changed significantly.

Conclusions

Early detection and diagnosis of caries based on risk indicators and risk factor assessments are effective. Furthermore, minimally invasive restorative techniques are beneficial in managing dental caries and preserving healthy tissue and should be used whenever possible. This new information, knowledge, and materials should encourage professionals to implement this method. Having a strategy and system based on patient-centred care is critical, and our dental responsibilities must prioritise patient-centred care.

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.

Clinical performance of a new fissure sealant-results from a 2-year randomized clinical trial

Objectives

The aim of this randomized clinical trial (RCT) was to explore the clinical survival of a new, Bis-GMA-free pit and fissure sealant (Helioseal F Plus) in comparison to an established control material (Helioseal F).

Material and methods

This in vivo study was designed as a prospective, 2-year, two-centre RCT with a split-mouth design. The initial study population consisted of 92 adolescents who were followed up 1 month (N = 89), 6 months (N = 88), 1 year (N = 85) and 2 years (N = 82) after sealant application. The attrition rate was 10.9% after 2 years. At each examination, the sealant retention and presence of caries were recorded. The statistical analysis included the calculation of Kaplan–Meier survival curves, log-rank tests and a Cox proportional hazard regression model.

Results

No adverse events during the application or any of the follow-up visits were documented. The proportion of completely intact sealants and those with minimal loss was almost identical in both groups at 85.9% (Helioseal F Plus) and 86.5% Helioseal F) after 2 years of observation. The regression analysis revealed operator dependency; no significant differences were found between the materials, the study centres, the chosen isolation technique and patient age or sex.

Conclusion

The newly developed sealant can be evaluated as at least equivalent in terms of survival and retention behaviour compared to the established control material.

Clinical relevance

The new sealant can be recommended for clinical use. With respect to the material properties (Bis-GMA-free, less light polymerisation time and better thixotropic behaviour), it offers additional advantages with clinical relevance.

Interventions for treating cavitated or dentine carious lesions

BACKGROUND

Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

OBJECTIVES

To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

SEARCH METHODS

An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

MAIN RESULTS

We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

AUTHORS' CONCLUSIONS

Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.