Selective versus stepwise removal of deep carious lesions in permanent teeth: a randomised controlled trial from Egypt-an interim analysis

Association of Papacarie Duo® and low-level laser in antimicrobial photodynamic therapy (aPDT)

Dental caries is a multifactorial, non-communicable disease. Effective treatment options for minimally invasive removal of carious tissue include Papacarie Duo® gel and antimicrobial photodynamic therapy (aPDT). aPDT involves a combination of a light source and photosensitizer. Given that Papacarie Duo® contains a percentage of blue dye, this study aims to explore the antimicrobial potential of Papacarie Duo® when associated with a light source against Streptococcus mutans strains. The chosen light source was a low-power diode laser (λ = 660 nm, E = 3 J, P = 100 mW, t = 30 s). To assess antimicrobial capacity, planktonic suspensions of Streptococcus mutans were plated on Brain Heart Infusion Agar (BHI) to observe the formation of inhibition halos. The studied groups included methylene blue (0.005%), Papacarie Duo®, distilled water (negative control), 2% chlorhexidine (positive control), Papacarie Duo® + laser, and methylene blue (0.005%) + laser. Following distribution onto plates, each group was incubated at 37 °C for 48 h under microaerophilic conditions. Inhibition halos were subsequently measured using a digital caliper. The results showed that chlorhexidine had the greatest antimicrobial effect followed by the group of irradiated methylene blue and irradiated Papacarie Duo®. All experimental groups demonstrated antimicrobial potential, excluding the negative control group. The study concludes that Papacarie Duo® exhibits antimicrobial properties when associated with a low-power diode laser.

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

BACKGROUND

An expert panel convened by the American Dental Association (ADA) Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated caries lesions in patients with vital, nonendodontically treated primary and permanent teeth.

TYPES OF STUDIES REVIEWED

The authors searched for systematic reviews comparing carious tissue removal (CTR) approaches in Ovid MEDLINE, Embase, Cochrane Database of Systematic Reviews, and Trip Medical Database. The authors also conducted a systematic search for randomized controlled trials comparing direct restorative materials in Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. The authors used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of the evidence and formulate recommendations.

RESULTS

The panel formulated 16 recommendations and good practice statements: 4 on CTR approaches specific to lesion depth and 12 on direct restorative materials specific to tooth location and surfaces involved. The panel conditionally recommended for the use of conservative CTR approaches, especially for advanced lesions. Although the panel conditionally recommended for the use of all direct restorative materials, they prioritized some materials over the use of others for certain clinical scenarios.

PRACTICAL IMPLICATIONS

The evidence suggests that more conservative CTR approaches may decrease the risk of adverse effects. All included direct restorative materials may be effective in treating moderate and advanced caries lesions on vital, nonendodontically treated primary and permanent teeth.

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.

Selective versus stepwise removal of deep carious lesions: A meta-analysis of randomized controlled trials

Background/purpose

Stepwise removal (SWR) and selective removal (SCR) are proposed techniques to treat deep carious lesions, but it is currently uncertain which technique is better. This meta-analysis aimed to compare the therapeutic effects of SCR and SWR for deep carious lesions in both primary and permanent teeth.

Materials and methods

PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP databases were searched until June 9, 2021. Success was the primary outcome. Secondary outcomes included pulp exposure, tooth extraction, pulp necrosis, pulpitis, and endodontic treatment. The effect size of each outcome was tested for heterogeneity. The source of heterogeneity was explored by meta regression analysis. Subgroup analysis and sensitivity analysis were conducted for the outcomes.

Results

Nine studies of 1550 patients with 1929 deep carious teeth were included. SCR had a significantly higher success rate than SWR (pooled relative risk [RR] = 1.123, 95% confidence interval [CI] = 1.056-1.194, I² = 52.3%, P < 0.001). The incidence of pulp exposure was significantly lower in the SCR group than that in the SWR group (pooled RR = 0.266, 95%CI = 0.096-0.740, I² = 0.0%, P = 0.011). The incidence of pulp necrosis in the SCR group was approximately 14.2% of that in the SWR group (pooled RR = 0.142, 95%CI = 0.026-0.789, I² = 0.0%, P = 0.026). Compared with SWR, SCR reduced the incidence of pulpitis by about 76.3% (pooled RR = 0.237, 95%CI = 0.090-0.623, I² = 0.0%, P = 0.003).

Conclusion

SCR may be a better treatment for deep caries to achieve better outcomes than SWR. Future research on comparing SCR and SWR for different outcomes in deep carious lesions is warranted to confirm our findings.

Survival Analysis and Cost Effectiveness of Silver Modified Atraumatic Restorative Treatment (SMART) and ART Occlusal Restorations in Primary Molars: a randomized controlled trial

OBJECTIVE

To evaluate and compare the clinical performance and cost effectiveness of Silver Modified Atraumatic Restorative Treatment (SMART) and Atraumatic Restorative Treatment (ART) restorations in primary molars over 12 months follow up period.

MATERIALS AND METHODS

Sixty-seven children, aged 5-9 years old having at least one asymptomatic primary molar with active caries, were randomly assigned to either the test arm (SMART) or the control arm (ART). Clinical performance was assessed after 6 and 12-months using the modified United States Public Health Services criteria. The trial was registered at Clinical Trial.gov with a registration number (NCT03881020). Treatment time for each restoration was recorded, Kaplan-Meier survival analysis and the log-rank test were performed (p<0.05) and cost effectiveness was measured at the end of the study.

RESULTS

Both techniques showed comparable clinical performance and the mean survival time was 11.8 and 11.6 months for SMART and ART restorations respectively with no detected significant differences (p=0.416). Mean treatment time for SMART restorations (7.8 min.), however, was significantly lower than ART (15 min.) (p < 0.001). SMART technique, also, showed statistically significant lower mean total cost per restoration (p <0.001).

CONCLUSIONS

Though SMART and ART have comparable clinical performance and survival in single-surface occlusal restorations in primary molars, SMART is less time consuming and more cost effective.

CLINICAL SIGNIFICANCE

Using SMART technique could change paradigms in caries management. Being a patient friendly and cost-effective approach, it could be adopted as a superior treatment option when dealing with young children, those with behavioral and medical challenges and for promoting access to oral care among the underprivileged.

Cost-effectiveness of partial versus stepwise caries removal of deep caries lesions - a decision-analytic approach

OBJECTIVE

The aim was to compare the cost-effectiveness of partial caries removal (PCR) and stepwise caries removal (SW) in mature permanent teeth diagnosed with deep caries lesions, in a Swedish Public Dental Care organization.

MATERIALS AND METHODS

A decision tree model was used to calculate the cost-effectiveness for PCR and SW. Probability values were obtained through a literature search in PubMed and Scopus. Treatment times were estimated by a group of dentists practicing at public dental care clinics in Västra Götaland county, Sweden.

RESULTS

The expected costs for PCR and SW were 187,63 and 414,35 €, respectively, indicating that PCR was more cost-effective. Four articles were identified through the literature search. The p-values for PCR outcomes were 94% (success), 0% (pulp exposure) and 6% (pulpitis/apical periodontitis etc.). For SW, the p-values were 76% (success), 2% (pulp exposure during the first visit), 13% (pulp exposure during the second visit) and 9% (pulpitis/apical periodontitis etc.).

CONCLUSIONS

Given the presumptions in this decision analysis, the PCR method used on mature permanent teeth is more cost-effective (p < ,05) compared to the SW method in protecting the pulp from exposure and avoiding the need for root canal treatment.

Compliance of randomized controlled trials in posterior restorations with the CONSORT statement: a systematic review of methodology

OBJECTIVES

This study aims to investigate the compliance of randomized controlled trials (RCTs) in posterior restorations with the Consolidated Standards of Reporting Trials Statement (CONSORT) statement and to analyze the risk of bias (RoB) of these studies.

METHODS

A systematic search was performed in PubMed, Scopus, Web of Science, LILACS/BBO, and Cochrane Library. Only RCTs published in peer-reviewed journals were included. The compliance with the CONSORT was evaluated in a 0-2 scale where 0 = no description, 1 = poor description and 2 = adequate description. Descriptive analyses of the CONSORT mean score by journal, country, and RoB were performed. The RoB in RCTs was evaluated by using the Cochrane Collaboration's tool version 1.0.

RESULTS

A total of 15,476 studies were identified after duplicates removal. O only 202 meet the eligibility criteria, among which 31 were follow-up studies. Concerning the overall RoB, only 29 out of 171 were classified as low risk of bias. The overall mean CONSORT score was 19 ± 5.4 points, which means compliance of approximately 59%. Significant differences among countries, publication period, and RoB were observed (p < 0.001). The journal's impact factor was not correlated with the overall CONSORT score (p = 0.36).

CONCLUSIONS

The adherence of RCTs conducted in posterior restorations to the CONSORT Statement is still low. In addition, most studies were classified as at unclear risk of bias. These results call up an urgent need for improvement.

CLINICAL RELEVANCE

Most RCTs conducted in posterior teeth have poor reporting and are mainly classified as having an unclear risk of bias.

Prognosis of Vital Pulp Therapy on Permanent Dentition: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

The aim of this systematic review was to evaluate the existing randomized controlled trials (RCTs) on the safety and efficacy of vital pulp therapy (VPT) and to analyze the outcomes of VPT performed with a variety of pulp-capping materials and techniques.

METHODS

MEDLINE (PubMed), Embase, Cochrane Library, and gray literature were searched (January 2000-March 2021). Study selection and data extraction were performed in duplicate. Eligible RCTs were critically appraised for risk of bias and quality of evidence and were meta-analyzed to estimate the treatment effects.

RESULTS

Fourteen studies were included. The pooled success rate of VPT using contemporary capping materials such as mineral trioxide aggregate (MTA) or calcium silicate-based materials (CSMs) was 93.2% (95% confidence interval [CI], 91.6%-94.9%). Multiple subgroup analyses by different etiologies, procedure types, developmental stages of teeth, and preoperative diagnoses were performed. Analyses presented low certainty of evidence. No significant difference was noted between MTA and CSM at 12 months or a longer follow-up (risk ratio = 0.99; 95% CI, 0.95-1.03) with low certainty of evidence. Laser-assisted VPT failed to show significantly better outcomes than conventional VPT (risk ratio = 1.19; 95% CI, 0.99-1.49) with very low certainty of evidence.

CONCLUSIONS

When MTA or CSM was used as a capping material, VPT was 93% successful. The techniques, etiologies, developmental stages of teeth, and preoperative diagnosis had no significant influence on treatment outcomes. No major adverse effects (except discoloration associated with the use of MTA) were identified. The overall quality of evidence was low.

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.

Cost-effectiveness of glass hybrid versus composite in a multi-country randomized trial

OBJECTIVES

We assessed the cost-effectiveness of two amalgam alternatives, glass hybrid (GH) and composite (CO) in a multi-country randomized controlled split-mouth trial.

MATERIALS

University clinics in Croatia, Serbia, Italy and Turkey participated. Pairs of GH (EQUIA Forte, GC) and a nano-hybrid CO (TetricEvoCeram, IvoclarVivadent) were randomly placed in occlusal-proximal two-surfaced cavities in permanent molars of adults (n = 180/360 patients/molars). We used 3-years interim data for this evaluation. FDI-2 criteria were applied and teeth requiring repair, re-restoration, endodontic treatment or extraction recorded. Our outcome was the time until any or major complications (requiring endodontic treatment or extraction) occurred. Costs were calculated in US Dollar (USD) 2018, with the local currencies being converted using Purchasing Power Parities. To estimate initial and re-treatment costs, a payers' perspective was taken and direct medical costs estimated from fee item catalogues. Incremental-cost-effectiveness ratios (ICER) were used to express the cost difference per gained or lost effectiveness.

RESULTS

Overall costs were lower for GH than CO in Croatia, Turkey and Serbia, while this difference was minimal in Italy. GH tended to survive longer than CO in Croatia and Italy, and shorter in Serbia and Turkey; overall survival time was not significantly different (p = 0.67/log-rank). The cost-effectiveness differences indicated CO to be more expensive at limited (ICER: 268.5 USD/month without any complications) or no benefit at all (-186.2 USD/month without major complications).

CONCLUSIONS

GH was less costly than CO both initially and over 3 years. Efficacy differences were extremely limited.

CLINICAL SIGNIFICANCE

Given their low initial costs and as efficacy between GH and CO did not differ significantly, GH had a high chance of being more cost-effective within this specific trial.

Improving the Bond Strength of Radiographically Tagged Caries Lesions In Vitro

After selective carious tissue removal, residual carious lesions remain radiographically detectable. Radiopaque tagging resolves the resulting diagnostic uncertainty but impedes bond strengths of adhesives to tagged dentin. We developed a protocol mitigating these detrimental effects. A 30%/50%/70% SnCl₂ solution was dissolved in distilled water or a 30%/50%/90% ethanol solution (E30/60/90) and applied to artificially induced dentin lesions. Tagging effects were radiographically evaluated using transversal wavelength-independent microradiography (n = 6/group). Groups with sufficient tagging effects at the lowest SnCl₂ concentrations were used to evaluate how tagging affected the microtensile bond strength of a universal adhesive (Scotchbond Universal) to sound and carious dentin (n = 10/group). Two different protocols for removing tagging material were tested: 15 s phosphoric acid etching and 5 s rotating brush application. Scanning/backscattered electron microscopy (SEM/BSE) and energy-dispersive X-ray spectroscopy (EDS) were used to assess surfaces after tagging and removal. The most promising removal protocol was revalidated microradiographically. Tagging significantly increased the radiopacity, with consistent effects for 30% SnCl₂ dissolved in water or E30. Microscopically, tagged surfaces showed a thick carpet of SnCl₂, and tagging reduced bond strengths significantly on carious dentin but not on sound dentin (p < 0.01). On carious dentin, removal of tagging material using acid etching and rotating brush was microscopically confirmed. Acid etching also mitigated any bond strength reduction (median: 21.3 MPa; interquartile range: 10.8 MPa) compared with nontagged dentin (median: 17.4 MPa; interquartile range: 20.6 MPa). This was not the case for brushing (median: 13.2 MPa; interquartile range: 13.9 MPa). Acid etching minimally reduced the radiographic tagging effect (p = 0.055). Phosphoric acid etching reduces the detrimental bond-strength effects of tagging without significantly decreasing radiographic tagging effects when using a universal adhesive.

Restorations after selective caries removal: 5-Year randomized trial

OBJECTIVE

To compare the survival of restorations placed in deep caries lesions after selective caries removal to soft dentin (SCRSD) over a 5-year period. A secondary aim was to investigate whether the material (amalgam or resin composite) affected the survival of restorations.

METHODS

This study used data derived from a multicenter randomized controlled clinical trial (Clinical trials registration NCT00887952). Inclusion criteria were: patients with permanent molars presenting occlusal or proximal deep caries lesions (≥1/2 of the dentin thickness on radiographic examination), positive response to a cold test, absence of spontaneous pain, negative sensitivity to percussion, and absence of periapical lesions. The teeth were randomized into SCRSD and restoration in a single visit or stepwise excavation (SW). Each of these groups was divided according to the filling material: amalgam (AM) or resin composite (RC). Survival analyses were performed to estimate therapy success rates over 5 years (adjusted Weibull regression model).

RESULTS

172 restorations were evaluated, 95 from SCRSD group and 77 from SW group, being 61 AMG and 111 RC. The 5-year survival analysis showed similar success rates for SW (76 %) and SCRSD (79 %) as well as for AM and RC (p > 0.05).

CONCLUSION

This study showed that, after a 5-year follow-up period, the presence of decayed tissue beneath restorations in deep caries lesions did not seem to affect restoration survival. Amalgam and resin composite restorations had similar survival rates, irrespective of the caries removal technique used - SCRSD or SW.

CLINICAL SIGNIFICANCE

Selective caries removal to soft dentin can be used in the management of deep caries to avoid pulp exposure and preserve tooth structure without affecting restoration longevity.