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

Equivalence study of the resin-dentine interface of internal tunnel restorations when using an enamel infiltrant resin with ethanol-wet dentine bonding

This preregistered ex vivo investigation examined the dentinal hybrid layer formation of a resinous infiltrant (Icon), with reference to both thickness (HLT) and homogeneity when combined with modified tunnel preparation (occlusal cavity only) and internal/external caries infiltration. The adhesives Syntac and Scotchbond MP were used as controls (Groups 1 and 3) or in combination with Icon (Groups 2 and 4). A split-tooth design using healthy third molars from 20 donors resulted in 20 prepared dentine cavities per experimental group. The cavity surfaces (n = 80) were etched (37% H3PO4), rinsed, and air-dried. Rewetting with ethanol was followed by application of the respective primers. After labeling with fluorescent dyes, either Syntac Adhesive/Heliobond or Scotchbond MP Adhesive was used alone or supplemented with Icon. HLT, as evaluated by scanning electron microscopy, did not significantly differ (P > 0.05), and confocal laser scanning microscopy revealed homogeneously mixed/polymerized resin-dentine interdiffusion zones in all groups. Icon can be successfully integrated into an ethanol-wet dentine bonding strategy, and will result in compact and homogeneous hybrid layers of comparable thickness considered equivalent to the non-Icon controls, thus allowing for preservation of the tooth's marginal ridge and interdental space in the case of internal/external infiltration of proximal caries.

Does the liner material influence pulpal vitality in deep carious cavities submitted to selective caries removal? A network meta-analysis review

OBJECTIVES

To evaluate whether the restorative material in direct contact with the dentin influences pulp vitality in primary and permanent teeth with deep carious lesions restored after selective caries removal (SCR).

MATERIAL AND METHODS

Systematic searches of databases MEDLINE via PubMed, Scopus and ISI Web of Science were performed for primary and permanent teeth. Inclusion criteria were applied for title and abstract reading of databases search results. After full texts review of included studies, those that did not meet exclusion criteria were excluded from meta-analysis.

RESULTS

For meta-analysis, 2 studies were included for permanent teeth and 6 for primary teeth. The failure events reported were meta-analyzed using two statistical methods: standard pairwise meta-analysis (SPMA) and network meta-analysis (NMA). The SPMA identified similar failure occurrence of restorations performed with calcium hydroxide (CH) and other liner materials (RR 0.84, 95% CI 0.41, 1.74; p = 0.64), no significant difference between the use of alternative liners or CH regardless deciduous or permanent teeth (RR 0.79, 95% CI 0.36, 1.71; p = 0.55) and similar risk of failing at different follow-ups for all liner materials tested (RR 0.77, 95% CI 0.35, 1.70; p = 0.52). Probabilistic analysis indicated GIC as liner material with the highest probability of clinical success (SUCRA = 72.76%), and CH ranked as the worst liner material (SUCRA = 21.81%).

CONCLUSION

Pulpal vitality was not affected by material used as liner after selective caries removal in deep carious cavities.

CLINICAL RELEVANCE

Current clinical evidence supports the weak recommendation to not use calcium hydroxide as liner after SCR.

The revolutionary evolution in carious lesion management

Contemporary paradigms of dental caries management focus on the biological approaches to treating the disease and its principal symptom, the carious lesion. This narrative review traces the evolution of carious lesion management from the operative and invasive approaches of G. V. Black's era to the current period of minimally invasive biological approaches. The paper explains the rationale for adopting biological approaches to dental caries management and lists the five core principles of this management approach. The paper also details the aims, features, and the most recent evidence base for the different biological carious lesion management approaches. Based on current practice guidelines, collated clinical pathways for lesion management are also presented in the paper to aid clinicians in their decision-making. It is hoped that the biological rationale and evidence summarized in this paper will bolster the shift to modern biological carious lesion management approaches among dental practitioners.

Dental Pulp Response to Silver-Containing Solutions: A Scoping Review

Dentists used silver-containing solutions for deep cavity disinfection before restoration. This review aims to identify the silver-containing solutions reported in the literature for deep cavity disinfection and summarize their effects on dental pulp. An extensive search was performed using the search words "(silver) AND (dental pulp OR pulp)" in ProQuest, PubMed, SCOPUS, and Web of Science to identify English publications on silver-containing solutions for cavity conditioning. The pulpal response to the included silver-containing solutions was summarized. The initial search identified 4112 publications and 14 publications met the inclusion criteria. Silver fluoride, silver nitrate, silver diamine nitrate, silver diamine fluoride, and nano-silver fluoride were used in deep cavities for antimicrobial purposes. Indirect silver fluoride application induced pulp inflammation and reparative dentine in most cases, and pulp necrosis in some cases. Direct silver nitrate application caused blood clots and a wide inflammatory band in the pulp, whilst indirect silver nitrate application caused hypoplasia in shallow cavities and partial pulp necrosis in deep cavities. Direct silver diamine fluoride application induced pulp necrosis, while indirect silver diamine fluoride application induced a mild inflammatory response and reparative dentine formation. No evidence of the dental pulpal response to silver diamine nitrate or nano-silver fluoride was available in the literature.

A concise review of dental sealants in caries management

This concise review provides an update of the use of dental sealants. Dental sealants protect a tooth from caries development by providing a physical barrier to microorganism colonisation and creating a favorable environment for patients to clean. Some sealants release fluoride ions to promote remineralization. Dental sealants can be applied on pits and fissures of primary and permanent teeth to prevent and arrest early enamel caries. They are effective in caries prevention. The preventive fraction of resin sealant is up to 61% after 5 years. Dental sealants can be classified as resin, glass ionomer and hybrid (compomer or giomer) according to the material. Recent studies from 2012 to 2022 showed resin sealant has a high retention rate of up to 80% after 2 years, whereas glass ionomer sealants is 44%. Chemical etching with 37% phosphoric acid is the standard of care, whereas laser or air-abrasion cannot does not increase the sealant retention rate. Moist control is critical and studies found the use of rubber dam and cotton rolls had similar success for sealant retention. The longevity of dental sealant is also associated with clinical operative factors, including approaches of moisture control, enamel pretreatment, selection of dental adhesive, and time of acid etching.

Future Perspectives in Pediatric Dentistry: Where are We Now and where are We Heading?

Oral diseases in children are still a major public health problem that can negatively impact parents and their children's quality of life. Even though oral diseases are largely preventable, initial signs of them can be detected in the 1st year of life, and its severity might increase with time if no preventive measures are taken. Based on this, we aim to discuss "where is pediatric dentistry now?" and "where is pediatric dentistry heading?" Early life oral health conditions are a good predictor of oral health status in adolescence, adulthood, and elderly people. A healthy childhood provides the foundation and opportunities for life; therefore, pediatric dentists have the unique opportunity to identify the presence of unhealthy habits in the 1st year of life and educate the parents and family members to change them for life. If all educational and preventive strategies fail or are not put into practice, the child might present oral health problems, such as dental caries, erosive tooth wear (ETW), hypomineralization, and malocclusion, that could have a great impact on other stages of life. At the moment, in pediatric dentistry, there are many alternatives to prevent and treat these oral health problems. However, if prevention fails, minimally invasive approaches, and new dental materials and technologies have been developed recently and will be important tools available in the near future in order to enhance children's oral health.

How to cite this article

Rodrigues JA, Olegario I, Assunção CM, et al. Future Perspectives in Pediatric Dentistry: Where are We Now and where are We Heading? Int J Clin Pediatr Dent 2022;15(6):793-797.

COMPARATIVE EVALUATION OF A FISSURE SEALANT AND A FLOWABLE COMPOSITE: A 36-MONTH SPLIT-MOUTH, RANDOMIZED CLINICAL STUDY

OBJECTIVES

The purpose of the present clinical evaluation was to investigate the effect of a fissure sealant and a flowable composite at fissures of permanent molars in terms of retention and caries-incidence rates over a 36-month period.

METHODS

Thirty-four patients, ages varied from 16 to 22 years, diagnosed with at least 2 non-cavitated pit-and-fissure caries in the first and second molars were involved in the study. A total of 220 sealants, were placed in 117 upper molars and 103 lower molars. Teeth were sealed with either a flowable resin composite (Tetric Evo Flow) or a sealant material (Helioseal F)(n=110). Each restoration was evaluated in terms of retention and caries incidence at 6, 12, 24 and 36 months according to their location as well. Data were analyzed using Mann-Whitney U, Friedman and 1-way ANOVA tests at p < 0.05.

RESULTS

Tetric Evo Flow showed total retention with 95.5%, 93.8%, 88.5% and 80.2% at 6, 12, 24 and 36-month follow-ups respectively, while Helioseal F had retention rates of 95.5%, 94.8%, 85.4% and 80.2% respectively. After 36-months, there were 6 subjects totally lost in Helioseal F group, whereas 7 of the Tetric Evo Flow sunjects were totally lost. Caries development was firstly detected at 12-month evaluation for both of the materials however, no significant differences were observed among materials in retention rates or caries incidence after 36-month follow-ups (p>0.05).

SIGNIFICANCE

Using the flowable composite found as effective as the fissure sealant after 36-months regarding retention and caries incidence rates.

Sealants for preventing dental caries in primary teeth

BACKGROUND

Pit and fissure sealants are plastic materials that are used to seal deep pits and fissures on the occlusal surfaces of teeth, where decay occurs most often in children and adolescents. Deep pits and fissures can retain food debris and bacteria, making them difficult to clean, thereby causing them to be more susceptible to dental caries. The application of a pit and fissure sealant, a non-invasive preventive approach, can prevent dental caries by forming a protective barrier that reduces food entrapment and bacterial growth. Though moderate-certainty evidence shows that sealants are effective in preventing caries in permanent teeth, the effectiveness of applying pit and fissure sealants to primary teeth has yet to be established.

OBJECTIVES

To evaluate the effects of sealants compared to no sealant or a different sealant in preventing pit and fissure caries on the occlusal surfaces of primary molars in children and to report the adverse effects and the retention of different types of sealants.

SEARCH METHODS

An information specialist searched four bibliographic databases up to 11 February 2021 and used additional search methods to identify published, unpublished and ongoing studies. Review authors scanned the reference lists of included studies and relevant systematic reviews for further studies.

SELECTION CRITERIA

We included parallel-group and split-mouth randomised controlled trials (RCTs) that compared a sealant with no sealant, or different types of sealants, for the prevention of caries in primary molars, with no restriction on follow-up duration. We included studies in which co-interventions such as oral health preventive measures, oral health education or tooth brushing demonstrations were used, provided that the same adjunct was used with the intervention and comparator. We excluded studies with complex interventions for the prevention of dental caries in primary teeth such as preventive resin restorations, or studies that used sealants in cavitated carious lesions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed risk of bias of included studies. We presented outcomes for the development of new carious lesions on occlusal surfaces of primary molars as odds ratios (OR) with 95% confidence intervals (CIs). Where studies were similar in clinical and methodological characteristics, we planned to pool effect estimates using a random-effects model where appropriate. We used GRADE methodology to assess the certainty of the evidence.

MAIN RESULTS

We included nine studies that randomised 1120 children who ranged in age from 18 months to eight years at the start of the study. One study compared fluoride-releasing resin-based sealant with no sealant (139 tooth pairs in 90 children); two studies compared glass ionomer-based sealant with no sealant (619 children); two studies compared glass ionomer-based sealant with resin-based sealant (278 tooth pairs in 200 children); two studies compared fluoride-releasing resin-based sealant with resin-based sealant (113 tooth pairs in 69 children); one study compared composite with fluoride-releasing resin-based sealant (40 tooth pairs in 40 children); and one study compared autopolymerised sealant with light polymerised sealant (52 tooth pairs in 52 children). Three studies evaluated the effects of sealants versus no sealant and provided data for our primary outcome. Due to differences in study design such as age of participants and duration of follow-up, we elected not to pool the data. At 24 months, there was insufficient evidence of a difference in the development of new caries lesions for the fluoride-releasing sealants or no treatment groups (Becker Balagtas odds ratio (BB OR) 0.76, 95% CI 0.41 to 1.42; 1 study, 85 children, 255 tooth surfaces). For glass ionomer-based sealants, the evidence was equivocal; one study found insufficient evidence of a difference at follow-up between 12 and 30 months (OR 0.97, 95% CI 0.63 to 1.49; 449 children), while another with 12-month follow-up found a large, beneficial effect of sealants (OR 0.03, 95% CI 0.01 to 0.15; 107 children). We judged the certainty of the evidence to be low, downgrading two levels in total for study limitations, imprecision and inconsistency. We included six trials randomising 411 children that directly compared different sealant materials, four of which (221 children) provided data for our primary outcome. Differences in age of the participants and duration of follow-up precluded pooling of the data. The incidence of development of new caries lesions was typically low across the different sealant types evaluated. We judged the certainty of the evidence to be low or very low for the outcome of caries incidence. Only one study assessed and reported adverse events, the nature of which was gag reflex while placing the sealant material.

AUTHORS' CONCLUSIONS

The certainty of the evidence for the comparisons and outcomes in this review was low or very low, reflecting the fragility and uncertainty of the evidence base. The volume of evidence for this review was limited, which typically included small studies where the number of events was low. The majority of studies in this review were of split-mouth design, an efficient study design for this research question; however, there were often shortcomings in the analysis and reporting of results that made synthesising the evidence difficult. An important omission from the included studies was the reporting of adverse events. Given the importance of prevention for maintaining good oral health, there exists an important evidence gap pertaining to the caries-preventive effect and retention of sealants in the primary dentition, which should be addressed through robust RCTs.

Minimal intervention dentistry for managing carious lesions into dentine in primary teeth: an umbrella review

PURPOSE

This umbrella review systematically appraised published systematic reviews on Minimal Intervention Dentistry interventions carried out to manage dentine carious primary teeth to determine how best to translate the available evidence into practice, and to provide recommendations for what requires further research.

METHOD

An experienced information specialist searched MEDLINE, Embase, Cochrane Database of Systematic Reviews, Epistemonikos, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, and the NIHR Journals Library. In addition, the PROSPERO database was searched to identify forthcoming systematic reviews. Searches were built around the following four concepts: primary teeth AND caries/carious lesion AND Minimal Intervention Dentistry AND systematic review/meta-analysis. Searches were restricted to English language, systematic reviews with/without meta-analyses published between January 2000 and August 2020. Two reviewers independently screened all titles and abstracts. Interventions included involved no dentine carious tissue removal (fissure sealants, resin infiltration, topical application of 38% Silver Diamine Fluoride, and Hall Technique), non-restorative caries control, and selective removal of carious tissue involving both stepwise excavation and atraumatic restorative treatment. Systematic reviews were selected, data extracted, and risk of bias assessed using ROBIS by two independent reviewers. Studies overlap was calculated using corrected covered area.

RESULTS

Eighteen systematic reviews were included in total; 8 assessed the caries arresting effects of 38% Silver Demine Fluoride (SDF), 1 on the Hall Technique (HT), 1 on selective removal of carious tissue, and eight investigated interventions using atraumatic restorative treatment (ART). Included systematic reviews were published between 2006 and 2020, covering a defined time frame of included randomised controlled trials ranging from 1969 to 2018. Systematic reviews assessed the sealing efficacy of fissure sealants and resin infiltration in carious primary teeth were excluded due to pooled data reporting on caries arrest in both enamel and outer third of dentine with the majority of these carious lesions being limited to enamel. Therefore, fissure sealants and resin infiltration are not recommended for the management of dentinal caries lesions in primary teeth. Topical application of 38% SDF showed a significant caries arrest effect in primary teeth (p < 0.05), and its success rate in arresting dental caries increased when it was applied twice (range between 53 and 91%) rather than once a year (range between 31 and 79%). Data on HT were limited and revealed that preformed metal crowns placed using the HT were likely to reduce discomfort at time of treatment, the risk of major failure (pulp treatment or extraction needed) and pain compared to conventional restorations. Selective removal of carious tissue particularly in deep carious lesions has significantly reduced the risk of pulp exposure (77% and 69% risk reduction with one-step selective caries removal and stepwise excavation, respectively). ART showed higher success rate when placed in single surface compared to multi-surface cavities (86% and 48.7-88%, respectively, over 3 years follow-up).

CONCLUSION

Minimal Intervention Dentistry techniques, namely 38% SDF, HT, selective removal of carious tissue, and ART for single surface cavity, appear to be effective in arresting the progress of dentinal caries in primary teeth when compared to no treatment, or conventional restorations. There is clear need to increase the emphasis on considering these techniques for managing carious primary teeth as a mainstream option rather than a compromise option in circumstances where the conventional approach is not possible due to cooperation or cost.

Sealing of cavitated occlusal carious lesions in the dentine of deciduous molars: a two-year randomised controlled clinical trial

OBJECTIVES

This two-arm, parallel-group, tooth-randomised, controlled noninferiority clinical trial aimed to compare survival rates between the sealing and restoring of cavitated occlusal carious lesions in dentine [International Caries Detection and Assessment System (ICDAS) 5] of deciduous molars using resin-modified glass-ionomer cement (RMGIC) and to assess caries progression radiographically.

MATERIALS AND METHODS

A total of 68 molars with ICDAS 5 occlusal lesions were randomly allocated into two groups, a sealing group (n = 31), in which RMGIC was placed directly over the carious lesion, and a restoration group (n = 37), in which a restoration with the same material was placed after selective caries removal. During the baseline and follow-up visits, dental caries was registered and caries activity was assessed according to a visuotactile criterion. At baseline, patient caries status (dmf-t) and cavity depth and extent (mesiodistal and buccolingual) were measured before RMGIC placement. An independent and blinded examiner evaluated the treated teeth using the USPHS criteria after one and two years. Standardised interproximal radiographs were taken for caries progression assessments.

RESULTS

During the follow-up period, no lesion progression was observed radiographically. After one year (n = 60; 27 sealed and 33 restored) and two years (n = 48; 23 sealed and 25 restored) of follow-up, the treatment success rates were 78.8% and 76.0% in the restoration group and 59.3% and 47.8% in the sealing group, respectively. Multivariate Cox regression showed that lesions smaller than 2 mm in the mesiodistal extent were less prone to fail after one year (p = 0.03). However, survival curves (log-rank test) were statistically significantly different only after two years (p < 0.001).

CONCLUSIONS

Sealing ICDAS 5 occlusal lesions of deciduous molars using RMGIC achieved lower survival rates than restorations. Both sealing and restoration effectively arrested caries progression for two years. Clinical relevance Sealing dentine carious lesions can be effective for treating lesions involving the inner and outer half of the dentine. Ultraconservative treatments can arrest carious lesions presenting obvious cavitation in primary molars.

TRIAL REGISTRATION

ReBEC Register no. RBR-225n35.

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.

Management of dental caries lesions in Latin American and Caribbean countries

Caries management at the lesion level is dependent on the lesion activity, the presence of a cavitation (either cleanable or non-cleanable), and lesion depth as evaluated via radiographic examination. A variety of non-invasive, micro-invasive, and minimally invasive treatment (with or without restoration) options are available for primary and permanent teeth. Non-invasive strategies include oral hygiene instructions, dietary counseling, and personal as well as professional use of fluoridated products that reduce demineralization and increase re-mineralization. Micro-invasive procedures include the use of occlusal resin sealants and resin infiltrants, while minimally invasive strategies comprise those related to selective removal of caries tissues and placement of restorations. Deep caries management includes indirect pulp capping, while exposed pulp may be treated using direct pulp capping and partial or complete pulpotomy. The aim of the present study was to review available evidence on recommended preventive and restorative strategies for caries lesions in Latin American/Caribbean countries, and subsequently develop evidence-based recommendations for treatment options that take into consideration material availability, emphasize ways to adapt available treatments to the local context, and suggest ways in which dentists and health systems can adopt these treatments.

Evaluation of the re-mineralization capacity of a gold nanoparticle-based dental varnish: An in vitro study

Background

Dental caries is an infectious microbial disease caused by acidogenic bacteria. It leads to the dissolution of enamel, dentin, and cementum. Enamel demineralization is often appreciated as' 'White Chalky lesions or Chalky enamel''. Standard procedures for protection of these teeth are fissure sealing and topical fluoride application. A varnish is generally a material in which a resin such as copal is dissolved within an organic solvent such as ethanol. Gold is one of the most biocompatible dental materials. Gold nanoparticles were biosynthesised using aspartic acid in previous studies.

Aim and Objectives

To prepare a gold nanoparticle based dental varnish and to evaluate its re-mineralizing capacity.

Materials and Methods

Gold nanoparticle dental varnish was prepared using all the necessary constituents. This newly prepared dental varnish was compared with G.C Fuji/SnF2 dental varnish. Demineralizing capacity of the dental varnishes were analysed. The tooth specimens were prepared according to methodology and mounted on resin blocks. They were subjected to demineralization remineralization cycles. ICP-OES and Knoop Hardness tests were performed.

Results

AuNP dental varnish had a satisfactory remineralization effect on demineralised enamel. For calcium analysis, the AuNP group showed significantly more total calcium loss when compared to the SnF2 group (P < 0.05) and was statistically significant. For phosphorus analysis, AuNP group showed significantly greater net phosphorus loss compared to the SnF2 group (P < 0.05) and was statistically significant. It was also observed that the KHN increased more significantly in Group A (SnF2) as compared to Group B (AuNP) and was also statistically significant (P < 0.05).

Conclusion

AuNP dental varnish showed considerable re mineralizing property; however, it was not superior to dental varnishes like SnF2 dental varnish. Further research needs to be done in vitro to better modify the AuNP dental varnish before proceeding to in vivo studies.

Effectiveness of pit and fissure sealants on primary molars: A 2-yr split-mouth randomized clinical trial

The primary objective of this study was to evaluate the effects of sealants in preventing pit and fissure caries in primary molars. The secondary objective was to assess the sealant retention during a 2-yr study period. A 2-yr split-mouth randomized clinical trial including 90 3-7-yr-old children was conducted in the paediatric dental department of Montpellier hospital. The dentition of each included patient was divided into an experimental side and a control side, with annual follow-up visits. Caries increments, measured as the number of new occlusal cavitated lesions, were not different between the sealed (mean 0.23) and the control primary molars (mean 0.29). A multiple mixed-effects logistic regression showed that male gender, moderate/high caries risk, and a higher oral hygiene index score, had a statistically significant effect resulting in higher caries increments in the primary molars, than did female gender, low caries risk, and lower oral hygiene index scores. Sealing showed no statistically significant influence on the development of new caries lesions. After 2 yr, the percentages of partially or totally lost sealants were 22.7% and 32.0%, respectively. In this sample of children, the caries increment was not significantly different between the sealed and the unsealed molars. At the end of this 2-yr study, more than half of the sealants were totally or partially lost, which could explain the low sealant effectiveness.

When to intervene in the caries process? A Delphi consensus statement

Objectives To define an expert Delphi consensus on when to intervene in the caries process and existing carious lesions.Methods Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.Results Lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations may be placed for form, function, aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated lesions which are cleansable. Cavitated lesions which are not cleansable usually require minimally invasive management. In specific circumstances, mixed interventions may be applicable. Occlusally, cavitated lesions confined to enamel/non-cavitated lesions extending radiographically into deep dentine may be exceptions. Proximally, cavitation is hard to assess tactile-visually. Most lesions extending radiographically into the middle/inner third of dentine are assumed to be cavitated. Those restricted to the enamel are not cavitated. For lesions extending radiographically into the outer third of dentine, cavitation is unlikely. These lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds.Conclusions Comprehensive diagnosis is the basis for systematic decision-making on when to intervene in the caries process and existing lesions.

Selective vs stepwise removal of deep carious lesions in primary molars: 24 months follow-up from a randomized controlled trial

Objectives

For well-defined deep (> 2/3 dentin extension) carious lesions, selective (SE) or stepwise (SW) carious tissue removals have been recommended, while there is limited comparative evidence for both. We compared SE and SW over 24 months in a randomized controlled trial.

Methods

A two-arm superiority trial was conducted comparing SW/SE in primary molars without pulpal symptoms but well-defined deep lesions. Seventy-four children (1 molar/child) aged 3–9 years were recruited. In a first step, peripheral carious tissue was removed until hard dentin remained, while in proximity to the pulp, leathery dentin was left. An adhesive compomer restoration was placed and restorations re-examined after 6 months. In SW, re-entry and removal to firm dentin was conducted pulpo-proximally, followed by re-restoration. Molars were re-evaluated for a total of 24 months. Our primary outcome was success (absence of restorative/endodontic complications or pulp exposures). Secondary outcomes included total treatment and opportunity costs and restoration quality, assessed using modified USPHS criteria.

Results

After 24 months, 63 molars (31 SE, 32 SW) were re-assessed. Four failures occurred (2 exposures in SW; 2 pulpal complications in SE, 1 of them leading to extraction, p > 0.05). Restoration integrity was satisfying in both groups (USPHS A/B/C in 21/8/0 SE and 23/7/0 SW, p > 0.05). Treatment and opportunity costs were significantly higher in SW than SE (mean 171 ± 51 vs. 106 ± 90; p < 0.001).

Conclusions

After 2 years, SE and SW showed similar efficacy for managing deep carious lesions in primary molars. The higher costs for SW should be considered during decision-making.

Clinical significance

In primary molars with well-defined deep carious lesions SE was less costly and similarly efficacious like SW. From a cost and applicability perspective, SW may need to be indicated restrictively, e.g., for very deep (> 3/4 dentin extension) lesions only.

Trial registration

ClinicalTrials.gov Identifier: NCT02232828

How to Intervene in the Caries Process: Dentin Caries in Primary Teeth

For an ORCA/EFCD consensus, this review systematically assessed available evidence regarding interventions performed and materials used to manage dentin carious lesions in primary teeth. A search for systematic reviews (SRs) and randomized clinical trials (RCTs) with a follow-up of at least 12 months after intervention was performed in PubMed, LILACS, BBO, and the Cochrane Library. The risk of bias tool from the Cochrane Collaboration and the PRISMA Statement were used for assessment of the included studies. From 101 screened articles, 2 SRs and 5 RCTs, which assessed the effectiveness of interventions in terms of pulp vitality and success of restoration, and 10 SRs and 1 RCT assessing the success of restorative materials were included. For treatments involving no carious tissue removal, the Hall technique showed lower treatment failure for approximal carious lesions compared to complete caries removal (CCR) and filling. For the treatment of deep carious lesions, techniques involving selective caries removal (SCR) showed a reduction in the incidence of pulp exposure. However, the benefit of SCR over CCR in terms of pulp symptoms or restoration success/failure was not confirmed. Regarding restorative materials, preformed metal crowns (PMCs) used to restore multisurface lesions showed the highest success rates compared to other restorative materials (amalgam, composite resin, glass ionomer cement, and compomer), and in the long term (12-48 months) these were also less likely to fail. There is limited evidence supporting the use of PMCs to restore carious lesions with single cavities. Among nonrestorative options, silver diammine fluoride was significantly more effective in arresting caries than other treatments for treating active carious lesions of different depths. Considerable heterogeneity and bias risk were observed in the included studies. Although heterogeneity observed among the studies was substantial, the trends were similar. In conclusion, less invasive caries approaches involving selective or no caries removal seem advantageous in comparison to CCR for patients presenting with vital, symptomless, carious dentin lesions in primary teeth. There is evidence in favor of PMCs for restoring multisurface carious lesions in primary molars.

Maintaining pulpal vitality: Cost-effectiveness analysis on carious tissue removal and direct pulp capping

OBJECTIVES

When managing deep carious lesions, dentists can maintain pulp vitality via (1) avoiding pulp exposure and complications by performing selective (SE) instead of non-selective (NS) carious tissue removal, and/or (2) treat exposed pulps by direct capping with mineral-trioxide-aggregate (MTA) instead of calcium hydroxide (CH). We assessed the cost-effectiveness of SE vs. NS combined with direct pulp capping using MTA vs. CH.

METHODS

A mixed public-private-payer perspective within German healthcare was applied. We modeled a permanent molar with a deep carious lesion and a vital asymptomatic pulp. The lesion was treated by SE/NS and, in case of exposure, direct pulp capping using MTA/CH. The tooth was followed over the lifetime of an initially 30-year-old patient using Markov-models, informed by pairwise and Bayesian network meta-analyses and further data sources. The primary health outcome was tooth-retention time. Costs were derived from German fee item catalogues, combined with micro-costing. Monte-Carlo micro-simulation was performed, and uncertainty introduced via probabilistic and univariate sensitivity analyses. Value-of-information-analysis (VOI) was performed to quantify the value of further research.

RESULTS

SE and, in case of pulp exposure, MTA had a high chance (>95 %) of being cost-effective, with teeth being retained for 37.37 years at costs of 2140 Euro in mean. Alternative strategies were both more costly and less effective; this ranking was robust in sensitivity analyses. The VOI was 1.18 Euro per treated case and 12.86 million Euro on population-level.

CONCLUSION

Selective carious tissue removal and, in case of pulp exposure, direct capping with MTA was the most cost-effective strategy.

CLINICAL SIGNIFICANCE

Avoiding pulp exposure was more relevant for cost-effectiveness than how the exposed pulp was managed. Overall differences remain limited, though, and dentists may want to tailor treatment strategies according to their expertise and patients' expectations.

Clinical and radiographic evaluation of indirect pulp treatment of young permanent molars using photo-activated oral disinfection versus calcium hydroxide: a randomized controlled pilot trial

Background

Calcium hydroxide is the most commonly used material in indirect pulp treatment (IPT). However, its drawbacks required its replacement by other materials.

Aim

This study aims to estimate clinically and radiographically the success of indirect pulp treatment of young permanent molars with either photo-activated oral disinfection (PAD) or calcium hydroxide.

Design

This Randomized Controlled Pilot Trial included 32 vital first permanent molars with deep caries that were treated by indirect pulp treatment with either PAD (group 1) or calcium hydroxide (group 2). Clinical and radiographic success in addition to newly-formed dentin thickness were evaluated regularly at 2, 6, 9, and 12 months.

Results

The success for both groups was 100% clinically and radiographically at all follow-up periods. Regarding the mean thickness of newly-formed dentin for both groups at different follow-up periods, there was no statistically significant difference between both groups at 2, 6, 9, and 12 months, with P values = 0.825, 0.146, 0.280, and 0.400, respectively.

Conclusions

The clinical and radiographic success for indirect pulp treatment of young permanent molars with both PAD and calcium hydroxide were comparable.

Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT

BACKGROUND

Historically, lack of evidence for effective management of decay in primary teeth has caused uncertainty, but there is emerging evidence to support alternative strategies to conventional fillings, which are minimally invasive and prevention orientated.

OBJECTIVES

The objectives were (1) to assess the clinical effectiveness and cost-effectiveness of three strategies for managing caries in primary teeth and (2) to assess quality of life, dental anxiety, the acceptability and experiences of children, parents and dental professionals, and caries development and/or progression.

DESIGN

This was a multicentre, three-arm parallel-group, participant-randomised controlled trial. Allocation concealment was achieved by use of a centralised web-based randomisation facility hosted by Newcastle Clinical Trials Unit.

SETTING

This trial was set in primary dental care in Scotland, England and Wales.

PARTICIPANTS

Participants were NHS patients aged 3-7 years who were at a high risk of tooth decay and had at least one primary molar tooth with decay into dentine, but no pain/sepsis.

INTERVENTIONS

Three interventions were employed: (1) conventional with best-practice prevention (local anaesthetic, carious tissue removal, filling placement), (2) biological with best-practice prevention (sealing-in decay, selective carious tissue removal and fissure sealants) and (3) best-practice prevention alone (dietary and toothbrushing advice, topical fluoride and fissure sealing of permanent teeth).

MAIN OUTCOME MEASURES

The clinical effectiveness outcomes were the proportion of children with at least one episode (incidence) and the number of episodes, for each child, of dental pain or dental sepsis or both over the follow-up period. The cost-effectiveness outcomes were the cost per incidence of, and cost per episode of, dental pain and/or dental sepsis avoided over the follow-up period.

RESULTS

A total of 72 dental practices were recruited and 1144 participants were randomised (conventional arm, n = 386; biological arm, n = 381; prevention alone arm, n = 377). Of these, 1058 were included in an intention-to-treat analysis (conventional arm, n = 352; biological arm, n = 352; prevention alone arm, n = 354). The median follow-up time was 33.8 months (interquartile range 23.8-36.7 months). The proportion of children with at least one episode of pain or sepsis or both was 42% (conventional arm), 40% (biological arm) and 45% (prevention alone arm). There was no evidence of a difference in incidence or episodes of pain/sepsis between arms. When comparing the biological arm with the conventional arm, the risk difference was -0.02 (97.5% confidence interval -0.10 to 0.06), which indicates, on average, a 2% reduced risk of dental pain and/or dental sepsis in the biological arm compared with the conventional arm. Comparing the prevention alone arm with the conventional arm, the risk difference was 0.04 (97.5% confidence interval -0.04 to 0.12), which indicates, on average, a 4% increased risk of dental pain and/or dental sepsis in the prevention alone arm compared with the conventional arm. Compared with the conventional arm, there was no evidence of a difference in episodes of pain/sepsis among children in the biological arm (incident rate ratio 0.95, 97.5% confidence interval 0.75 to 1.21, which indicates that there were slightly fewer episodes, on average, in the biological arm than the conventional arm) or in the prevention alone arm (incident rate ratio 1.18, 97.5% confidence interval 0.94 to 1.48, which indicates that there were slightly more episodes in the prevention alone arm than the conventional arm). Over the willingness-to-pay values considered, the probability of the biological treatment approach being considered cost-effective was approximately no higher than 60% to avoid an incidence of dental pain and/or dental sepsis and no higher than 70% to avoid an episode of pain/sepsis.

CONCLUSIONS

There was no evidence of an overall difference between the three treatment approaches for experience of, or number of episodes of, dental pain or dental sepsis or both over the follow-up period.

FUTURE WORK

Recommendations for future work include exploring barriers to the use of conventional techniques for carious lesion detection and diagnosis (e.g. radiographs) and developing and evaluating suitable techniques and strategies for use in young children in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77044005.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 1. See the NIHR Journals Library website for further project information.

When to intervene in the caries process? An expert Delphi consensus statement

OBJECTIVES

To define an expert Delphi consensus on when to intervene in the caries process and on existing carious lesions using non- or micro-invasive, invasive/restorative or mixed interventions.

METHODS

Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.

RESULTS

Carious lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations will be placed for reasons of form, function and aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated carious lesions which are cleansable. Cavitated lesions which are not cleansable usually require invasive/restorative management, to restore form, function and aesthetics. In specific circumstances, mixed interventions may be applicable. On occlusal surfaces, cavitated lesions confined to enamel and non-cavitated lesions radiographically extending deep into dentine (middle or inner dentine third, D2/3) may be exceptions to that rule. On proximal surfaces, cavitation is hard to assess visually or by using tactile methods. Hence, radiographic lesion depth is used to determine the likelihood of cavitation. Most lesions radiographically extending into the middle or inner third of the dentine (D2/3) can be assumed to be cavitated, while those restricted to the enamel (E1/2) are not cavitated. For lesions radiographically extending into the outer third of the dentine (D1), cavitation is unlikely, and these lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds.

CONCLUSIONS

Comprehensive diagnostics are the basis for systematic decision-making on when to intervene in the caries process and on existing carious lesions.

CLINICAL RELEVANCE

Carious lesion activity, cavitation and cleansability determine intervention thresholds. Invasive treatments should be applied restrictively and with these factors in mind.

Microcavitated (ICDAS 3) carious lesion arrest with resin or glass ionomer sealants in first permanent molars: A randomized controlled trial

OBJECTIVES

Although there is some consensus that carious lesions in early stages (non-cavitated) could be treated using sealants, neither the type of materials nor their use in lesions with localized enamel breakdown (microcavitated) has been reported To compare the efficacy of resin or glass ionomer (GI) sealants in arresting microcavitated carious lesions (ICDAS 3) in first permanent molars.

MATERIALS AND METHODS

A double-blinded randomized controlled clinical trial was conducted in 41 healthy 6 to 11-year-old children. At the baseline examination, each subject had at least one carious lesion classified as ICDAS 3 on the first permanent molar. One hundred fifty-one lesions were randomized into: Group 1: resin sealants (76 lesions) and Group 2: GI sealant (75 lesions). Carious lesion progression was assessed clinically and radiographically. Progression and retention failure were the outcomes used for group comparisons at p-value<0.05.

RESULTS

After a two-year follow-up, only one lesion progressed to ICDAS 5, without statistically significant differences between the groups (χ²(1) = 0.90, p = 0.53). Radiographically, 100 lesions (98%) were arrested and 2 (2%) showed radiographic progression, without differences between groups (χ²(1) = 0.93, p = 0.93). At 2 years, complete retention was observed in 77% of the resin-based and in 83% of the GI sealants, without statistical differences between type of sealant (χ²(1) = 0.71, p = 0.48). The multilevel mixed model demonstrated that location and type of sealant did not affect retention rates (χ²(1) = 24,98, p < 0.001).

CONCLUSION

Sealing ICDAS 3 carious lesions in permanent molars appears to be effective in arresting lesions after a two-year follow-up. Clinicaltrials.gov: RCTICDAS3/2015.

CLINICAL SIGNIFICANCE

Minimally invasive approaches for carious lesion management have been promoted. Using sealants for the treatment of microcavitated lesions (ICDAS 3) appears predictable in the routine practice, without predilection for resin or glass ionomer materials. In addition to preserving tooth structure, this strategy reduces chair-time, dental fear and costs, and increases coverage to dental care.

Dental caries lesions in primary teeth without obvious cavitation: Treatment decision-making process

BACKGROUND

Dental caries diagnosis and management have changed over time.

AIM

To identify the treatment decision-making process performed by paediatric dentists, after caries detection using CAST instrument (Caries Assessment Spectrum and Treatment), for enamel (CAST 3) and non-cavitated dentin caries lesions (CAST 4) before and after analysing radiographic images.

DESIGN

Seventy-four paediatric dentists were invited to participate. Twelve clinical cases were presented online, and treatment decisions before and after the analysis of bitewing radiographs were evaluated.

RESULTS

Sixty-one specialists answered the questionnaire. The necessity for radiographs was significantly associated with the presence and depth of the caries lesion (P < 0.0001). CAST 3 lesions were preferentially monitored before and after the radiographic assessment. For CAST 4 lesions limited to the outer half of dentin, treatments indicated before and after radiographic analysis were sealant (33%) and restoration (40%). For the lesions in the inner half of dentin, restoration was the most cited before (45%) and after (84%) radiographs. The radiographic depth was the only significant independent variable when "change in the treatment option" was analysed by the regression model (P < 0.001).

CONCLUSIONS

Enamel lesions were treated through less invasive treatments. Radiographs influenced the decision, especially for the lesions that involved the inner half of dentin.

Tailored Dentistry: From "One Size Fits All" to Precision Dental Medicine?

Over the past 30 years and fueled by both a rapidly evolving understanding of dental diseases and technological advances in diagnostics and therapy, dentistry has been changing dramatically. Managing dental caries and carious lesions had, for nearly a century, encompassed only a small number of basic concepts that were applied to virtually all patients and lesions, namely, invasive removal of any carious tissue regardless of its activity or depth and its replacement with restorative materials (amalgams or crowns for most of the past) or tooth removal and prosthetic replacement. Grounded in a deeper understanding of the disease "caries," its management-aiming to control the causes of the disease, to slow down or alleviate existing disease, and, only as a last resort, to remove its symptoms using a bur or forceps-has become more complex and diverse. In parallel and at nearly unprecedented speed, our patients are changing, as mirrored by ongoing debates as to the demographic and, with it, the social future of most high-income countries. This article describes how these changes will have a profound future impact on how we practice dental medicine in the future. It will deduce, from both demographic and epidemiologic trends, why there is the need to apply not one but rather the whole range of existing evidence-based concepts in an individualized (personalized) manner, hence increasing the effectiveness and efficiency of dental management strategies, and also describe how these strategies should be tailored according not only to our patients (their age and risk profiles) but also to the specific tooth (or site or lesion).

Scientific evidence for the management of dentin caries lesions in pediatric dentistry: A systematic review and network meta-analysis

BACKGROUND

A systematic quantitative evaluation of the available evidence of the treatment for caries lesions in primary teeth that considers how different caries progressions lead to the need for distinct interventions might provide additional useful information for clinical evidence-based decision making. The aim of this systematic review and network meta-analysis was to verify the effect of the treatments on caries lesion arrestment (CLA) or the success rate (SR) of dentin caries lesion treatments in the primary teeth.

METHODS

A search was conducted using the MEDLINE/PubMed, Web of Science and Scopus databases through December 2017. The primary search terms used in combination were primary teeth, caries lesion and restoration. The grey literature was also screened, as were the reference lists of eligible studies. A search of prospective studies with at least 12 months of follow up that compared different techniques was performed. The exclusion criteria were the absence of a comparison group; no evaluation of different restorative techniques; the evaluation of other outcomes unrelated to this review; and the recruitment of specific patient. The risk of bias was evaluated by the tools: the Cochrane Handbook for Systematic Reviews of Interventions and ROBINS-I. A network meta-analyses and meta-analyses were conducted considering CLA or SR as outcomes according to the surface involved and the depth of progression.

RESULTS

Of the 1671 potentially eligible studies, 15 were included. For occlusal surfaces, only two studies presented data regarding the outer half of the dentin, with conventional restorative treatment (CRT) using composite resin showing superior results; five studies presented data regarding the depth of caries lesions, and CRT with compomer resulted in the best results. Seven studies considered occlusoproximal surfaces, and the Hall technique showed the best SR among the evaluated treatments. Finally, two annual applications of silver diamine fluoride showed the best nonrestorative approach to arrest caries lesions on occlusal and smooth surfaces.

DISCUSSION/CONCLUSIONS

The treatments for dentin caries lesions in primary teeth depend on the depth of progression and the surface involved. However, few of the included studies provided evidence to strongly recommend the best treatment option.

OTHER

Funding: FAPESP; Systematic review registration number-PROSPERO CRD42016037784.

Efficacy of sealing occlusal caries with a flowable composite in primary molars: A 2-year randomized controlled clinical trial

OBJECTIVES

This randomized controlled clinical trial evaluated the efficacy of sealing carious dentin in controlling the progression of lesions in primary molars for 2-year follow-up.

MATERIALS AND METHODS

Children (6.79 ± 1.81 years, n = 28) presenting primary molars with occlusal caries in the outer half of dentine were randomized and allocated into 2 groups: test (sealing caries with a flowable resin - SC) and control (partial removal of caries followed by restoration - PRC). The primary outcomes were: the clinical success of restorations evaluated by USPHS criteria and the radiographic analysis of caries progression. The children anxiety was evaluated by a Facial Image Scale; and the time required to perform the treatments was registered.

RESULTS

In 21 patients evaluated after 2 years, 48 primary molars were analyzed. Clinically, there was no difference between the groups. There was no difference between treatments (p = 0.848) considering lesion progression. The anxiety level did not change after the two interventions (p = 0.650). The treatment time of SC (9.03 ± 1.91 min) was lower (p = 0.002) than the PRC time (17.13 ± 5.26 min).

CONCLUSION

Sealing carious dentin may be used in dentistry since it did not alter the children anxiety, reduced the chair time and demonstrated clinical success rate and no radiographic difference in relation to the partial caries removal followed by restoration.

Beyond Streptococcus mutans: clinical implications of the evolving dental caries aetiological paradigms and its associated microbiome

Aetiological concepts of dental caries have evolved over the years from being considered as a disease initiated by nonspecific microorganisms, to being regarded as an 'infectious' disease caused by specific bacteria, to the current paradigms that emphasise a 'mixed bacterial-ecological approach' as being responsible for lesion initiation and pathogenesis. These aetiological paradigms are not just intellectual concepts but have important implications on how clinicians manage this age-old disease in the twenty-first century. Despite evidence-backed recommendations for adopting more biological measures to counter the disease, a significant proportion of dentists continue following traditional caries management guidelines in their daily clinical practice. This paper will review the evolving dental caries aetiological concepts and highlight the current evidence for adopting a more ecological approach to caries prevention, risk assessment, and treatment.

Managing Carious Lesions: Consensus Recommendations on Terminology

Variation in the terminology used to describe clinical management of carious lesions has contributed to a lack of clarity in the scientific literature and beyond. In this article, the International Caries Consensus Collaboration presents 1) issues around terminology, a scoping review of current words used in the literature for caries removal techniques, and 2) agreed terms and definitions, explaining how these were decided.Dental cariesis the name of the disease, and thecarious lesionis the consequence and manifestation of the disease-the signs or symptoms of the disease. The termdental caries managementshould be limited to situations involving control of the disease through preventive and noninvasive means at a patient level, whereascarious lesion managementcontrols the disease symptoms at the tooth level. While it is not possible to directly relate the visual appearance of carious lesions' clinical manifestations to the histopathology, we have based the terminology around the clinical consequences of disease (soft, leathery, firm, and hard dentine). Approaches to carious tissue removal are defined: 1)selective removal of carious tissue-includingselective removal to soft dentineandselective removal to firm dentine; 2)stepwise removal-including stage 1,selective removal to soft dentine, and stage 2,selective removal to firm dentine6 to 12 mo later; and 3)nonselective removal to hard dentine-formerly known ascomplete caries removal(technique no longer recommended). Adoption of these terms, around managing dental caries and its sequelae, will facilitate improved understanding and communication among researchers and within dental educators and the wider clinical dentistry community.

A randomized clinical trial on the sealing of occlusal carious lesions: 3-4-year results

This randomized clinical trial aimed to assess the efficacy of sealing occlusal carious lesions in permanent teeth. The sample consisted of 54 occlusal carious lesions in permanent molars and premolars of 49 patients aged 8-43 years (median: 19 years). The inclusion criteria comprised the presence of a cavity with no access allowing biofilm control. The maximum depth of the lesion was the middle third of the dentin thickness, as assessed by bitewing radiography. The teeth were randomly assigned to sealant treatment (n = 28) or restorative treatment (n = 26). Clinical and radiographic examinations were performed after 1 year and after 3-4 years. The outcomes depended on the clinical performance of the sealant/restoration and the control of caries progression observed radiographically. Survival analysis was performed to assess success rates. Over the 3-4 years of monitoring, 2 sealants were totally lost, 1 needed repair, and 1 showed caries progression, totaling 4 failures in the sealant group. In the restoration group, 1 failure was observed (in need of repair). The success rates were 76% and 94% in the sealant and the restoration groups, respectively (p > 0.05). The sealing of occlusal carious lesions in permanent teeth succeeded in controlling caries over a 3-4-year period. However, sealed carious lesions require patient compliance in attending regular follow-ups to control the occurrence of clinical failures of the sealants.

Atraumatic Restorative Treatment compared to the Hall Technique for occluso-proximal cavities in primary molars: study protocol for a randomized controlled trial

Background

In many parts of the world, school-age children have high dental treatment needs; however, there is often low, or no, dental care provision. Although Atraumatic Restorative Treatment (ART) was developed to address this, its survival rate in occluso-proximal lesions is low. An alternative, the Hall Technique (HT) has shown better relative outcomes for occluso-proximal lesions, but has not been directly compared to ART or tested in field settings. This trial will compare ART and the HT for the most clinically- and cost-effective strategy for managing occluso-proximal lesions in primary molars, in a school setting, using low-technology and child-friendly dental techniques.

Methods/Design

This two-arm, parallel group, patient-randomized controlled, superiority trial will have treatment provided in schools. Schoolchildren (n = 124, age 6–8) with at least one occluso-proximal carious primary molar lesion will have random allocation to treatment with ART or HT. Baseline measures and outcome data will be assessed through participant report, clinical examination and parent report/questionnaires. The primary outcome is survival rate, a composite measure of absence of Minor Failures (a defect in the restoration/crown, but not interfering with tooth health) and Major Failures (signs or symptoms of irreversible pulp damage, such as dental fistula/abscess, tooth fracture or failures that cannot be repaired). Secondary outcomes are: (1) child-reported discomfort, (2) childrens’ and (3) parents’ concerns around dental appearance and (4) acceptability of treatments, (5) occlusal-vertical dimensions (OVD) changes, (6) plaque index, (7) gingival health, (8) decayed, missing, filled teeth in permanent teeth (DMFT)/decayed, missing, filled teeth in primary teeth (dmft), (9) oral health-related-quality of life, reported by children and parents/caregivers, (10) the incremental cost-effectiveness, and (11) operator effect. A trained and calibrated examiner will evaluate the treated teeth after 1 week, then 1, 6, 12, 24 and 36 months post treatment. Kaplan-Meier and Cox regression tests will be used to investigate the primary outcome. The Mann-Whitney or t test, Friedman test, paired t test or Wilcoxon test and Ordinal Logistic Regression Analysis will be used to analyze the secondary outcomes.

Discussion

The results of this trial will support decision-making by clinicians and policy-makers for managing occluso-proximal lesions in settings with constrained resources and limited dental access.

Trial registration

www.clinicaltrials.gov, NCT02569047, registered 5 October 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1270-z) contains supplementary material, which is available to authorized users.

Risk of initial and moderate caries lesions in primary teeth to progress to dentine cavitation: a 2-year cohort study

AIM

To investigate the risk of sound surfaces, and initial and moderate caries lesions to progress to dentine cavitation in preschool children.

DESIGN

A cohort study was designed with 639 children (12-59 months old) who had been examined by visual inspection during a survey in 2010. After 2 years, 469 children were re-examined regarding the presence of dentine cavitations. The probability of progression was calculated for sound and carious (initial and moderate lesions) surfaces. Relative risk of progression and 95% confidence intervals for each condition compared with sound surfaces were calculated using multilevel Poisson regression analysis. Association with explanatory variables, including caries experience of the children, was also investigated.

RESULTS

The higher the initial score attributed to the dental surface, the more likely was the progression. Moreover, children with severe lesions at baseline had higher risk of having a sound surface or a non-cavitated caries lesion progressing to cavitation when compared with caries-free children; however, this increased risk was not observed in children with only initial caries lesions.

CONCLUSIONS

Initial caries lesions present a low frequency of progression. Moreover, sound surfaces and initial caries lesions in children already presenting cavitations are more likely to progress to more severe conditions.